Healthcare Provider Details

I. General information

NPI: 1770647869
Provider Name (Legal Business Name): MID-AMERICA SPINE & REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 OLD DES PERES RD
DES PERES MO
63131-1865
US

IV. Provider business mailing address

1030 OLD DES PERES RD
DES PERES MO
63131-1865
US

V. Phone/Fax

Practice location:
  • Phone: 314-966-8989
  • Fax: 314-966-0001
Mailing address:
  • Phone: 314-966-8989
  • Fax: 314-966-0001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number5905
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number01530
License Number StateMO

VIII. Authorized Official

Name: DR. ROBERT BRUCE EINERTSON
Title or Position: ADMINISTRATOR OWNER
Credential: D.C.
Phone: 314-966-8989