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General NPI Number Information
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NPI Number | 1982035440
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Entity Type | Organization
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Legal Business Name | EZELL CHIROPRACTIC LLC
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Dates
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Enumeration Date | 12/10/2013
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Last Update Date | 09/14/2022
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Provider Practice Location Address
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Address Line | 2201 1ST CAPITOL DR
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City | SAINT CHARLES
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State | MO
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Zip | 63301-5805
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Country | US
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Telephone | 636-916-0660
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Fax |
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Provider Business Mailing Address
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Address Line | 2201 1ST CAPITOL DR
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City | SAINT CHARLES
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State | MO
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Zip | 63301-5805
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Country | US
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Telephone | 636-916-0660
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Fax |
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Authorized Official
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Title or Position | OWNER/DOCTOR
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Name | DR. GLENN R. EZELL
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Credential | D.C.
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Telephone | 636-916-0660
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 2013000467
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 2013000467
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License Number State | MO
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