Healthcare Provider Details

I. General information

NPI: 1194041889
Provider Name (Legal Business Name): ST. LOUIS LASER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 04/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

763 S NEW BALLAS RD SUITE 230
CREVE COEUR MO
63141-8704
US

IV. Provider business mailing address

16412 GREEN PINES DR
BALLWIN MO
63011-1850
US

V. Phone/Fax

Practice location:
  • Phone: 314-681-2800
  • Fax: 314-432-5088
Mailing address:
  • Phone: 314-681-2800
  • Fax: 314-432-5088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberMO005286
License Number StateMO

VIII. Authorized Official

Name: DR. SCOTT FRANK HAINZ
Title or Position: OWNER/PHYSICIAN
Credential: DC
Phone: 314-378-6071