Healthcare Provider Details

I. General information

NPI: 1033177746
Provider Name (Legal Business Name): EDGAR EVERETT III D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 09/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 WOODSON RD STE #101
OVERLAND MO
63114-5644
US

IV. Provider business mailing address

2050 WOODSON RD STE #101
OVERLAND MO
63114-5644
US

V. Phone/Fax

Practice location:
  • Phone: 314-713-1656
  • Fax: 314-395-0607
Mailing address:
  • Phone: 314-713-1656
  • Fax: 314-395-0607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2006022760
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: