Healthcare Provider Details

I. General information

NPI: 1942137179
Provider Name (Legal Business Name): DAMEON LEE WILLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8641 WATSON RD
SAINT LOUIS MO
63119-5109
US

IV. Provider business mailing address

8641 WATSON RD
SAINT LOUIS MO
63119-5109
US

V. Phone/Fax

Practice location:
  • Phone: 314-962-3130
  • Fax: 314-962-7233
Mailing address:
  • Phone: 314-962-3130
  • Fax: 314-962-7233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2026019000
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: