Healthcare Provider Details

I. General information

NPI: 1912129016
Provider Name (Legal Business Name): JASON HENRY BLUMENFELD D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 RONNIE'S PLAZA
ST. LOUIS MO
63126-3552
US

IV. Provider business mailing address

14 RONNIE'S PLAZA
ST. LOUIS MO
63126-3552
US

V. Phone/Fax

Practice location:
  • Phone: 314-843-0490
  • Fax: 314-843-9186
Mailing address:
  • Phone: 314-843-0490
  • Fax: 314-843-9186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberMO 6068
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: