MEDICARE: CITY CHIROPRACTIC LLC

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	2012040930	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1821140112	OTHER		NPI

General Provider Information

NPI Number	:	1366975005
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY CHIROPRACTIC LLC

Provider Business Mailing Address
First Line	:	2618 HAMPTON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63139-2913
Country	:	US
Telephone Number	:	314-932-1228
Fax Number	:

Provider Business Practice Location Address
First Line	:	2618 HAMPTON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63139-2913
Country	:	US
Telephone Number	:	314-932-1228
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BRADY WILLIAMS
Credential	:	DC
Telephone Number	:	314-932-1228

Provider Enumeration Date	:	04/10/2017
Last Update Date	:	04/10/2017

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Directions to “CITY CHIROPRACTIC LLC ” Practice Location

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