Provider Demographics
NPI:1841457124
Name:CHIROPRACTIC CARE & SPORTS REHAB, INC.
Entity type:Organization
Organization Name:CHIROPRACTIC CARE & SPORTS REHAB, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:SCOGNAMIGLIO
Authorized Official - Last Name:REID
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CCSP
Authorized Official - Phone:314-439-5548
Mailing Address - Street 1:12401 OLIVE BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5448
Mailing Address - Country:US
Mailing Address - Phone:314-439-5548
Mailing Address - Fax:314-439-5766
Practice Address - Street 1:12401 OLIVE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-5448
Practice Address - Country:US
Practice Address - Phone:314-439-5548
Practice Address - Fax:314-439-5766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000031783Medicare PIN