Healthcare Provider Details

I. General information

NPI: 1477867166
Provider Name (Legal Business Name): CORNERSTONE CHIROPRACTOR CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2010
Last Update Date: 08/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 N WASHINGTON ST
SALEM MO
65560-1268
US

IV. Provider business mailing address

504 N WASHINGTON ST
SALEM MO
65560-1268
US

V. Phone/Fax

Practice location:
  • Phone: 573-729-5321
  • Fax: 573-729-1010
Mailing address:
  • Phone: 573-729-5321
  • Fax: 573-729-1010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number005352
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number005551
License Number StateMO

VIII. Authorized Official

Name: DR. BERNARD DONALD SIROIS JR.
Title or Position: CHIROPRACTOR
Credential: D.C.
Phone: 573-729-5321