Healthcare Provider Details

I. General information

NPI: 1770623811
Provider Name (Legal Business Name): PETER JOHN ROSCOE DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 04/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2821 N BALLAS RD STE C55
SAINT LOUIS MO
63131-2386
US

IV. Provider business mailing address

2821 N BALLAS RD STE C55
SAINT LOUIS MO
63131-2386
US

V. Phone/Fax

Practice location:
  • Phone: 314-989-1805
  • Fax:
Mailing address:
  • Phone: 314-542-2205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2001020193
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: