Healthcare Provider Details

I. General information

NPI: 1134744725
Provider Name (Legal Business Name): STL INJURY AND SPINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2020
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7721 CLAYTON RD
CLAYTON MO
63117-1301
US

IV. Provider business mailing address

7721 CLAYTON RD
CLAYTON MO
63117-1301
US

V. Phone/Fax

Practice location:
  • Phone: 314-546-6072
  • Fax: 888-569-4961
Mailing address:
  • Phone: 314-546-6072
  • Fax: 888-569-4961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JERRY LEECH
Title or Position: CEO
Credential: DC
Phone: 314-972-3107