1245574367 NPI number — ST. LOUIS OPTIMAL PERFORMANCE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245574367 NPI number — ST. LOUIS OPTIMAL PERFORMANCE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. LOUIS OPTIMAL PERFORMANCE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OPTIMAL PERFORMANCE CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245574367
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
219 CHESTERFIELD TOWNE CTR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESTERFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63005-1257
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-778-9997
Provider Business Mailing Address Fax Number:
636-778-9994

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
219 CHESTERFIELD TOWNE CTR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHESTERFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63005-1257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-778-9997
Provider Business Practice Location Address Fax Number:
636-778-9994
Provider Enumeration Date:
11/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
LAIDERMAN
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
ANDREW
Authorized Official Title or Position:
CHIROPRACTIC PHYSICIAN/OWNER
Authorized Official Telephone Number:
636-778-9997

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2012014238 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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