=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770647869
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MID-AMERICA SPINE & REHAB LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2006
-----------------------------------------------------
Last Update Date | 12/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1030 OLD DES PERES RD
-----------------------------------------------------
City | DES PERES
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63131-1865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-966-8989
-----------------------------------------------------
Fax | 314-966-0001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1030 OLD DES PERES RD
-----------------------------------------------------
City | DES PERES
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63131-1865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-966-8989
-----------------------------------------------------
Fax | 314-966-0001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR OWNER
-----------------------------------------------------
Name | DR. ROBERT BRUCE EINERTSON
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 314-966-8989
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 01530
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number | 5905
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------