Healthcare Provider Details

I. General information

NPI: 1063718732
Provider Name (Legal Business Name): DAVID CHRISTOPHER DECLUE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2011
Last Update Date: 01/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 TECHNOLOGY DR SUITE 107
O FALLON MO
63368-7370
US

IV. Provider business mailing address

1195 LINDEN DR
FLORISSANT MO
63031-4415
US

V. Phone/Fax

Practice location:
  • Phone: 314-607-1973
  • Fax:
Mailing address:
  • Phone: 314-607-1973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2011001913
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: