Healthcare Provider Details

I. General information

NPI: 1649623240
Provider Name (Legal Business Name): INTEGRATIVE SPINE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 11/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13710 OLIVE BLVD
CHESTERFIELD MO
63017-2602
US

IV. Provider business mailing address

13710 OLIVE BLVD
CHESTERFIELD MO
63017-2602
US

V. Phone/Fax

Practice location:
  • Phone: 314-469-7246
  • Fax: 314-469-7251
Mailing address:
  • Phone: 314-469-7246
  • Fax: 314-469-7251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number103749
License Number StateMO

VIII. Authorized Official

Name: MS. LATA SOLANKI
Title or Position: OFFICE MANAGER
Credential: B. SC
Phone: 314-469-7246