Healthcare Provider Details

I. General information

NPI: 1740956382
Provider Name (Legal Business Name): JOHN CICHON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 S KIRKWOOD RD STE 201
KIRKWOOD MO
63122-6161
US

IV. Provider business mailing address

14515 N OUTER 40 RD STE 110
CHESTERFIELD MO
63017-5746
US

V. Phone/Fax

Practice location:
  • Phone: 314-909-4848
  • Fax: 314-909-4824
Mailing address:
  • Phone: 314-434-8680
  • Fax: 314-453-9985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2021033607
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: