Healthcare Provider Details

I. General information

NPI: 1477659217
Provider Name (Legal Business Name): BACK PAIN INSTITUTE OF ST. LOUIS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 02/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11903 SAINT CHARLES ROCK RD
BRIDGETON MO
63044-2623
US

IV. Provider business mailing address

11903 SAINT CHARLES ROCK RD
BRIDGETON MO
63044-2623
US

V. Phone/Fax

Practice location:
  • Phone: 314-770-0900
  • Fax: 314-739-8569
Mailing address:
  • Phone: 314-770-0900
  • Fax: 314-739-8569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number003647
License Number StateMO

VIII. Authorized Official

Name: MR. HAROLD K GILBERTSON
Title or Position: OWNER
Credential: DC
Phone: 314-770-0900