Provider Demographics
NPI:1962525162
Name:ELLISVILLE CHIROPRACTIC, INJURY AND PAIN CLINIC,LLC
Entity type:Organization
Organization Name:ELLISVILLE CHIROPRACTIC, INJURY AND PAIN CLINIC,LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BELMAR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-256-0880
Mailing Address - Street 1:16075 MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2103
Mailing Address - Country:US
Mailing Address - Phone:636-256-0880
Mailing Address - Fax:636-256-9153
Practice Address - Street 1:16075 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2103
Practice Address - Country:US
Practice Address - Phone:636-256-0880
Practice Address - Fax:636-256-9153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006517111NR0400X
MO2001025911111NR0400X
MO2004030104225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO26-6639Medicare ID - Type UnspecifiedOPT IDENTIFICATION NUMBER