Healthcare Provider Details

I. General information

NPI: 1942698998
Provider Name (Legal Business Name): DIVAN CHIROPRACTIC AND SPORTS REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2014
Last Update Date: 12/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8045 BIG BEND BLVD 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:
Mailing address:
  • Phone: 314-961-7181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2014010441
License Number StateMO

VIII. Authorized Official

Name: MRS. JANA WILLISON
Title or Position: OFFICE MANAGER
Credential:
Phone: 314-961-7181