=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881020006
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN MICHAEL FAULKNER D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2013
-----------------------------------------------------
Last Update Date | 09/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6251 RONALD REAGAN DR
-----------------------------------------------------
City | LAKE ST LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63367-2665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-614-2139
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8 SHIPLEY CT
-----------------------------------------------------
City | SAINT CHARLES
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63303-3024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-330-0626
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2013018389
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------