Healthcare Provider Details

I. General information

NPI: 1225548290
Provider Name (Legal Business Name): BRENTWOOD PAINSTOP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2017
Last Update Date: 10/04/2017
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 TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number2014010441
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number2014010441
License Number StateMO

VIII. Authorized Official

Name: NICHOLAS J DIVAN
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 314-961-7181