Healthcare Provider Details

I. General information

NPI: 1124066592
Provider Name (Legal Business Name): ANNE CATHERINE ROULO D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6651 CHIPPEWA ST
SAINT LOUIS MO
63109-2538
US

IV. Provider business mailing address

4405 ROSA AVE
SAINT LOUIS MO
63116-2216
US

V. Phone/Fax

Practice location:
  • Phone: 314-644-2070
  • Fax:
Mailing address:
  • Phone: 314-484-0690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number2006000316
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: