MEDICARE: CHIROPRACTIC WELLNESS CONNECTION OF WEBSTER GROVES PLLC

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		MO

General Provider Information

NPI Number	:	1902233851
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHIROPRACTIC WELLNESS CONNECTION OF WEBSTER GROVES PLLC

Provider Business Mailing Address
First Line	:	26421 SOUTHFIELD RD
Second Line	:
City	:	LATHRUP VILLAGE
State	:	MI
Zip	:	48076-4528
Country	:	US
Telephone Number	:	248-905-5066
Fax Number	:	248-905-5069

Provider Business Practice Location Address
First Line	:	7501 BIG BEND BLVD
Second Line	:
City	:	WEBSTER GROVES
State	:	MO
Zip	:	63119-2103
Country	:	US
Telephone Number	:	314-644-5333
Fax Number	:	314-961-8884

Authorized Official
Title or Position	:	OWNER
Name	:	SOLOMON COGAN
Credential	:	D.C.
Telephone Number	:	248-471-5554

Provider Enumeration Date	:	10/07/2013
Last Update Date	:	02/21/2014

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