Healthcare Provider Details

I. General information

NPI: 1427392356
Provider Name (Legal Business Name): SPINE AND JOINT CARE OF FENTON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8005 MACKENZIE RD
SAINT LOUIS MO
63123-3518
US

IV. Provider business mailing address

8005 MACKENZIE RD
SAINT LOUIS MO
63123-3518
US

V. Phone/Fax

Practice location:
  • Phone: 314-353-4500
  • Fax: 314-353-4502
Mailing address:
  • Phone: 314-353-4500
  • Fax: 314-353-4502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number2008027067
License Number StateMO

VIII. Authorized Official

Name: DR. DANIELLE ANGELA SPATH
Title or Position: OWNER AND CLINICAL DIRECTOR
Credential: DC
Phone: 314-353-4500