Healthcare Provider Details

I. General information

NPI: 1992461776
Provider Name (Legal Business Name): ICAN CLINIC MO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2021
Last Update Date: 11/16/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 FOUR SEASONS SHOPPING CTR STE 110
CHESTERFIELD MO
63017-3173
US

IV. Provider business mailing address

106 FOUR SEASONS SHOPPING CTR STE 110
CHESTERFIELD MO
63017-3173
US

V. Phone/Fax

Practice location:
  • Phone: 618-254-2273
  • Fax:
Mailing address:
  • Phone: 618-254-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL HARBISON
Title or Position: OWNER
Credential: DC
Phone: 618-254-2273