Provider Demographics
NPI:1205157773
Name:CAMBRIDGE MEDICAL FOR MEN LLC
Entity type:Organization
Organization Name:CAMBRIDGE MEDICAL FOR MEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:P
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:314-401-9725
Mailing Address - Street 1:900 SOUTH HIGHWAY SUITE 300
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026
Mailing Address - Country:US
Mailing Address - Phone:800-333-1980
Mailing Address - Fax:636-326-9735
Practice Address - Street 1:900 S HIGHWAY DR STE 300
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2042
Practice Address - Country:US
Practice Address - Phone:800-333-1980
Practice Address - Fax:636-326-9735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-18
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty