1629135819 NPI number — BRANDON MANNIE D.C. 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 1629135819 NPI number — BRANDON MANNIE D.C. LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRANDON MANNIE D.C. 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:
DBA CLIFF ROAD 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:
1629135819
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4555 ERIN DRIVE
Provider Second Line Business Mailing Address:
210
Provider Business Mailing Address City Name:
EAGAN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-452-2225
Provider Business Mailing Address Fax Number:
651-686-6871

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4555 ERIN DR
Provider Second Line Business Practice Location Address:
210
Provider Business Practice Location Address City Name:
EAGAN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55122-3398
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-452-2225
Provider Business Practice Location Address Fax Number:
651-686-6871
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MANNIE
Authorized Official First Name:
BRANDON
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
651-452-2225

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  4553 , 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)





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