=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689975252
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH COUNTY REHAB, D.C., LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2010
-----------------------------------------------------
Last Update Date | 11/12/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350C VILLAGE SQUARE DR SUITE 1
-----------------------------------------------------
City | HAZELWOOD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63042-1800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-551-0000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 350C VILLAGE SQUARE DR SUITE 1
-----------------------------------------------------
City | HAZELWOOD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63042-1800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-551-0000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR/MEMBER
-----------------------------------------------------
Name | DR. JACOB H UTTERBACK
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 314-551-0000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | CE006295
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 2007000279
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------