Healthcare Provider Details

I. General information

NPI: 1730249251
Provider Name (Legal Business Name): BENJAMIN MICHAEL CLEMENS DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 GRAVOIS RD
HIGH RIDGE MO
63049-2625
US

IV. Provider business mailing address

914 MEADOW ACRES LN
SAINT LOUIS MO
63125-4647
US

V. Phone/Fax

Practice location:
  • Phone: 636-677-4345
  • Fax: 636-938-3204
Mailing address:
  • Phone: 314-616-7773
  • Fax: 636-938-3204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2002009580
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: