MEDICARE: DR. CLINTON J DANIELS D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	2010031861	MO

General Provider Information

NPI Number	:	1194033084
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CLINTON J DANIELS D.C.

Provider Business Mailing Address
First Line	:	3106 WYOMING ST
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63118-2130
Country	:	US
Telephone Number	:	314-600-6677
Fax Number	:

Provider Business Practice Location Address
First Line	:	3641 REAVIS BARRACKS RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63125-2438
Country	:	US
Telephone Number	:	314-531-8882
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2010
Last Update Date	:	09/14/2010

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