Healthcare Provider Details

I. General information

NPI: 1194169334
Provider Name (Legal Business Name): CRESTWOOD BACK AND NECK PAIN CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 04/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9109 WATSON RD
SAINT LOUIS MO
63126-2235
US

IV. Provider business mailing address

9109 WATSON RD
SAINT LOUIS MO
63126-2235
US

V. Phone/Fax

Practice location:
  • Phone: 314-961-4101
  • Fax:
Mailing address:
  • Phone: 314-961-4101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: NICK CALANDRO
Title or Position: OWNER
Credential:
Phone: 314-961-4101