Healthcare Provider Details

I. General information

NPI: 1992132104
Provider Name (Legal Business Name): HOLISTIC FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2013
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2918 SUTTON BLVD
MAPLEWOOD MO
63143-3012
US

IV. Provider business mailing address

2918 SUTTON BLVD
MAPLEWOOD MO
63143-3012
US

V. Phone/Fax

Practice location:
  • Phone: 314-781-0063
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number004609
License Number StateMO

VIII. Authorized Official

Name: LAURIE S BERGER
Title or Position: SOLE MBR
Credential: DC
Phone: 314-781-0063