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General NPI Number Information
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NPI Number | 1255639662
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Entity Type | Organization
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Legal Business Name | SPORTS AND FAMILY CHIROPRACTIC
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Dates
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Enumeration Date | 03/09/2011
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Last Update Date | 05/09/2011
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Provider Practice Location Address
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Address Line | 2315 TECHNOLOGY DR SUITE 107
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City | O FALLON
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State | MO
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Zip | 63368-7370
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Country | US
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Telephone | 636-625-8894
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Fax | 636-625-8710
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Provider Business Mailing Address
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Address Line | 2315 TECHNOLOGY DR SUITE 107
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City | O FALLON
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State | MO
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Zip | 63368-7370
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Country | US
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Telephone | 636-625-8894
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Fax | 636-625-8710
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Authorized Official
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Title or Position | CO-OWNER
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Name | DR. DAVID DECLUE
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Credential | D.C.
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Telephone | 636-625-8894
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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 | 2011001913
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License Number State | MO
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