Healthcare Provider Details

I. General information

NPI: 1649454661
Provider Name (Legal Business Name): LAKE ST. LOUIS CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 02/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2161 WEST TERRA LANE
OFALLON MO
63366-2366
US

IV. Provider business mailing address

2161 WEST TERRA LANE
OFALLON MO
63366-2366
US

V. Phone/Fax

Practice location:
  • Phone: 636-887-9003
  • Fax: 636-327-6090
Mailing address:
  • Phone: 636-887-9003
  • Fax: 636-327-6090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2007032057
License Number StateMO

VIII. Authorized Official

Name: JASON C FOWLER
Title or Position: OWNER
Credential: DC
Phone: 636-887-9003