1205933306 NPI number — DIANNE L. COMO, DC, PA

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 1205933306 NPI number — DIANNE L. COMO, DC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIANNE L. COMO, DC, PA
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:
BACK IN SHAPE CHIROPRACTIC
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:
1205933306
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
669 WINNETKA AVE N
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
GOLDEN VALLEY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55427-4574
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-595-9096
Provider Business Mailing Address Fax Number:
763-595-0291

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
669 WINNETKA AVE N
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
GOLDEN VALLEY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55427-4574
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-595-9096
Provider Business Practice Location Address Fax Number:
763-595-0291
Provider Enumeration Date:
09/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
COMO
Authorized Official First Name:
DIANNE
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
OWNER/PRESIDENT/CHIROPRACTOR
Authorized Official Telephone Number:
763-595-9096

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  3191 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 55F12CO . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 889027700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".