Provider Demographics
NPI:1053693309
Name:CROSS, ETHAN MICHAEL (DC)
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:MICHAEL
Last Name:CROSS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MO
Mailing Address - Zip Code:64683-2626
Mailing Address - Country:US
Mailing Address - Phone:660-359-4491
Mailing Address - Fax:660-359-4492
Practice Address - Street 1:1200 E 9TH ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MO
Practice Address - Zip Code:64683-2626
Practice Address - Country:US
Practice Address - Phone:660-359-4491
Practice Address - Fax:660-359-4492
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011030716111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor