=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669716031
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRENTWOOD SPINE CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2012
-----------------------------------------------------
Last Update Date | 01/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2202 S BRENTWOOD BLVD
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63144-1804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-600-6677
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2202 S BRENTWOOD BLVD
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63144-1804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-600-6677
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTIC PHYSICIAN
-----------------------------------------------------
Name | DR. CLINTON JOSEPH DANIELS
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 314-600-6677
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | 2010031861
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------