Healthcare Provider Details

I. General information

NPI: 1750766721
Provider Name (Legal Business Name): WINCHESTER SPINE AND SPORT OF PACIFIC-EUREKA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2015
Last Update Date: 07/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1043 E OSAGE ST
PACIFIC MO
63069-1710
US

IV. Provider business mailing address

1043 E OSAGE ST
PACIFIC MO
63069-1710
US

V. Phone/Fax

Practice location:
  • Phone: 636-356-5557
  • Fax: 636-356-5558
Mailing address:
  • Phone: 636-356-5557
  • Fax: 636-356-5558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: BRETT WINCHESTER
Title or Position: OWNER
Credential: DC
Phone: 636-356-5557