Provider Demographics
NPI:1215117510
Name:ADVANCED CHIROPRACTIC SPINE AND JOINT REHAB. PC
Entity type:Organization
Organization Name:ADVANCED CHIROPRACTIC SPINE AND JOINT REHAB. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-379-6267
Mailing Address - Street 1:204 W PITMAN ST STE C
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-2869
Mailing Address - Country:US
Mailing Address - Phone:636-379-6267
Mailing Address - Fax:636-980-8083
Practice Address - Street 1:204 W PITMAN ST STE C
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-2869
Practice Address - Country:US
Practice Address - Phone:636-379-6267
Practice Address - Fax:636-980-8083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006673111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty