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General NPI Number Information
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NPI Number | 1245574367
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Entity Type | Organization
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Legal Business Name | ST. LOUIS OPTIMAL PERFORMANCE, LLC
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Dates
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Enumeration Date | 11/15/2012
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Last Update Date | 07/02/2013
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Provider Practice Location Address
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Address Line | 219 CHESTERFIELD TOWNE CTR
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City | CHESTERFIELD
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State | MO
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Zip | 63005-1257
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Country | US
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Telephone | 636-778-9997
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Fax | 636-778-9994
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Provider Business Mailing Address
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Address Line | 219 CHESTERFIELD TOWNE CTR
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City | CHESTERFIELD
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State | MO
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Zip | 63005-1257
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Country | US
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Telephone | 636-778-9997
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Fax | 636-778-9994
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Authorized Official
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Title or Position | CHIROPRACTIC PHYSICIAN/OWNER
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Name | DR. BRIAN ANDREW LAIDERMAN
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Credential | D.C.
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Telephone | 636-778-9997
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 2012014238
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License Number State | MO
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