Healthcare Provider Details

I. General information

NPI: 1467744847
Provider Name (Legal Business Name): JASON GREGORY BIONDO D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2011
Last Update Date: 05/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1099 MILWAUKEE ST STE 240
KIRKWOOD MO
63122-7360
US

IV. Provider business mailing address

1099 MILWAUKEE ST STE 204
KIRKWOOD MO
63122-7360
US

V. Phone/Fax

Practice location:
  • Phone: 314-822-1502
  • Fax:
Mailing address:
  • Phone: 636-219-6598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2011012761
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: