Healthcare Provider Details

I. General information

NPI: 1114343704
Provider Name (Legal Business Name): NICHOLAS DIVAN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8045 BIG BEND BLVD STE 107
SAINT LOUIS MO
63119-2714
US

IV. Provider business mailing address

8045 BIG BEND BLVD STE 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 Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number2014010441
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: