Provider Demographics
NPI:1992461776
Name:ICAN CLINIC MO PC
Entity type:Organization
Organization Name:ICAN CLINIC MO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HARBISON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-254-2273
Mailing Address - Street 1:106 FOUR SEASONS SHOPPING CTR STE 110
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3173
Mailing Address - Country:US
Mailing Address - Phone:618-254-2273
Mailing Address - Fax:
Practice Address - Street 1:106 FOUR SEASONS SHOPPING CTR STE 110
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3173
Practice Address - Country:US
Practice Address - Phone:618-254-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPainGroup - Multi-Specialty