MEDICARE: ST LOUIS INJURY AND REHABILITATION CENTER, 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

General Provider Information

NPI Number	:	1609095405
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST LOUIS INJURY AND REHABILITATION CENTER, LLC

Provider Business Mailing Address
First Line	:	8045 BIG BEND BLVD
Second Line	:	SUITE 107
City	:	SAINT LOUIS
State	:	MO
Zip	:	63119-2714
Country	:	US
Telephone Number	:	314-961-7181
Fax Number	:	314-961-6323

Provider Business Practice Location Address
First Line	:	8045 BIG BEND BLVD
Second Line	:	SUITE 107
City	:	SAINT LOUIS
State	:	MO
Zip	:	63119-2714
Country	:	US
Telephone Number	:	314-961-7181
Fax Number	:	314-961-6323

Authorized Official
Title or Position	:	OWNER
Name	:	DR. WILLIAM D CRAGG
Credential	:	DC
Telephone Number	:	314-961-7181

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	05/15/2008

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Practice Location Address:

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Practice Location Address:

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1942698998 — DIVAN CHIROPRACTIC AND SPORTS REHABILITATION
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Practice Fax:

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