1588023956 NPI number — PRICE-BOURISAW FAMILY CHIROPRACTIC

Table of content: CHRISTINE LYNN VAN DYKE FNP (NPI 1659037109)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588023956 NPI number — PRICE-BOURISAW FAMILY CHIROPRACTIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRICE-BOURISAW FAMILY CHIROPRACTIC
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:
Provider Other Organization Name Type Code:
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:
1588023956
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8 WARSEN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WENTZVILLE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63385-4811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2917 STATE HIGHWAY K
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
O FALLON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63368
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-922-0586
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/15/2016

Additional Information

Authorized Official

Authorized Official Last Name:
PRICE-BOURISAW
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
NOELLE
Authorized Official Title or Position:
CHIROPRACTIC PHYSICIAN
Authorized Official Telephone Number:
314-922-0586

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2014006004 , 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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