Provider Demographics
NPI:1538597679
Name:ERNSTROM SPINAL REHAB LLC
Entity type:Organization
Organization Name:ERNSTROM SPINAL REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:ERNSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-520-7109
Mailing Address - Street 1:300 CHESTERFIELD CTR
Mailing Address - Street 2:SUITE 140
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-4867
Mailing Address - Country:US
Mailing Address - Phone:208-520-7109
Mailing Address - Fax:636-775-2075
Practice Address - Street 1:908 DORESAY LN
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-1450
Practice Address - Country:US
Practice Address - Phone:208-569-7825
Practice Address - Fax:636-775-2075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010016363111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty