Healthcare Provider Details

I. General information

NPI: 1548344070
Provider Name (Legal Business Name): STACEY LEIGH BLAIR DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8045 BIG BEND BLVD SUITE 107
SAINT LOUIS MO
63119-2714
US

IV. Provider business mailing address

8045 BIG BEND BLVD SUITE 107
SAINT LOUIS MO
63119-2714
US

V. Phone/Fax

Practice location:
  • Phone: 314-961-7181
  • Fax: 314-961-6323
Mailing address:
  • Phone: 314-961-7181
  • Fax: 314-961-6323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038.010887
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2006028734
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: