Healthcare Provider Details

I. General information

NPI: 1720035405
Provider Name (Legal Business Name): ESQUIRE SPORTS MEDICINE SOUTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 08/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11133 LINDBERGH BUS
SAINT LOUIS MO
63123-7810
US

IV. Provider business mailing address

11133 LINDBERGH BUS
SAINT LOUIS MO
63123-7810
US

V. Phone/Fax

Practice location:
  • Phone: 314-416-1960
  • Fax:
Mailing address:
  • Phone: 314-416-1960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number005985
License Number StateMO

VIII. Authorized Official

Name: THOMAS DAVIS
Title or Position: OWNER
Credential: DC
Phone: 314-416-1690