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NPI Code Detail

MEDICARE: AVDIC PAIN & REHAB CLINIC, LLC

MEDICARE: AVDIC PAIN & REHAB CLINIC, 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
1111N00000XChiropractor2012000714MO

General Provider Information

NPI Number : 1508125006
Entity Type Code : Organization
Provider Name (Legal Business Name) : AVDIC PAIN & REHAB CLINIC, LLC
Provider Business Mailing Address
First Line : 3193 LEMAY FERRY RD
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63125-4417
Country : US
Telephone Number : 314-537-1380
Fax Number :
Provider Business Practice Location Address
First Line : 3193 LEMAY FERRY RD
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63125-4417
Country : US
Telephone Number : 314-537-1380
Fax Number :
Authorized Official
Title or Position : OWNER/PROVIDER
Name : ADIS AVDIC
Credential :
Telephone Number : 314-537-1380
Provider Enumeration Date : 05/04/2012
Last Update Date : 11/07/2012

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