Healthcare Provider Details

I. General information

NPI: 1780839944
Provider Name (Legal Business Name): INCHIOSTRO CHIROPRACTIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 12/01/2008
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: KENNETH LAWRENCE INCHIOSTRO
Title or Position: OWNER
Credential: DC
Phone: 636-300-8089