Provider Demographics
NPI:1306170501
Name:JOHN DEANGELIS LLC
Entity type:Organization
Organization Name:JOHN DEANGELIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:DEANGELIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:330-219-6557
Mailing Address - Street 1:1000 LAKE SAINT BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAKE SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-1340
Mailing Address - Country:US
Mailing Address - Phone:636-695-4570
Mailing Address - Fax:636-625-4554
Practice Address - Street 1:1000 LAKE SAINT LOUIS BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAKE SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-1340
Practice Address - Country:US
Practice Address - Phone:636-695-4570
Practice Address - Fax:636-625-4554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-22
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009002883111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty