Healthcare Provider Details

I. General information

NPI: 1861950156
Provider Name (Legal Business Name): GRANT GASPARD DC, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12977 N 40 DR STE 212
SAINT LOUIS MO
63141-8655
US

IV. Provider business mailing address

12977 N 40 DR STE 212
SAINT LOUIS MO
63141-8655
US

V. Phone/Fax

Practice location:
  • Phone: 217-415-5789
  • Fax:
Mailing address:
  • Phone: 217-415-5789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2023002895
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: