Healthcare Provider Details

I. General information

NPI: 1396733598
Provider Name (Legal Business Name): JEFFREY D CARPENTER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 01/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 N MAIN ST
DE SOTO MO
63020-1709
US

IV. Provider business mailing address

112 N MAIN ST
DE SOTO MO
63020-1709
US

V. Phone/Fax

Practice location:
  • Phone: 636-586-4226
  • Fax: 636-586-3791
Mailing address:
  • Phone: 636-586-4226
  • Fax: 636-586-3791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2004035442
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: