Healthcare Provider Details

I. General information

NPI: 1295817179
Provider Name (Legal Business Name): BRUCE AARON CHAREST D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 KIMBERLING BLVD
KIMBERLING CITY MO
65686
US

IV. Provider business mailing address

PO BOX 765
KIMBERLING CITY MO
65686-0765
US

V. Phone/Fax

Practice location:
  • Phone: 417-739-4764
  • Fax:
Mailing address:
  • Phone: 417-739-4764
  • Fax: 417-739-4764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2015043019
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: