=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922639376
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAIRD SPINE AND SPORT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2020
-----------------------------------------------------
Last Update Date | 02/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 905 MAIN PLAZA DR
-----------------------------------------------------
City | WENTZVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63385-1168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-856-1260
-----------------------------------------------------
Fax | 636-856-1245
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 539 COPPER MEADOWS LN
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63368-3996
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-293-7788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOSHUA DAVID BAIRD
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 636-293-7788
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------