Healthcare Provider Details

I. General information

NPI: 1043404114
Provider Name (Legal Business Name): CRIDER CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2007
Last Update Date: 02/24/2012
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: 314-315-2868
  • Fax:
Mailing address:
  • Phone: 314-315-2868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number2007021516
License Number StateMO

VIII. Authorized Official

Name: DR. HEATHER RENE STALCUP
Title or Position: DOCTOR
Credential: D.C
Phone: 314-315-2868