=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942993175
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAIN RELIEF CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2023
-----------------------------------------------------
Last Update Date | 08/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 406 JUNGERMANN RD
-----------------------------------------------------
City | SAINT PETERS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63376-2764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-395-2852
-----------------------------------------------------
Fax | 636-244-1219
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 406 JUNGERMANN RD
-----------------------------------------------------
City | SAINT PETERS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63376-2764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-274-1571
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MATTHEW BURKS
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 619-274-1571
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------