=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225101876
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC NEIL WALTEMATE D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2006
-----------------------------------------------------
Last Update Date | 12/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11628 OLD BALLAS RD STE 112
-----------------------------------------------------
City | CREVE COEUR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-7030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-569-0057
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 339 S 5TH ST
-----------------------------------------------------
City | MASCOUTAH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62258-2303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-207-4445
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2002013828
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038.011402
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------