Healthcare Provider Details

I. General information

NPI: 1306999073
Provider Name (Legal Business Name): KENNETH LAWRENCE INCHIOSTRO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1043A WOLFRUM RD
WELDON SPRING MO
63304-7625
US

IV. Provider business mailing address

1043A WOLFRUM RD
WELDON SPRING MO
63304-7625
US

V. Phone/Fax

Practice location:
  • Phone: 636-300-8089
  • Fax: 636-300-8049
Mailing address:
  • Phone: 636-300-8089
  • Fax: 636-300-8049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2000172545
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: