1316281637 NPI number — EVOLUTION CHIROPRACTIC, P.A.

Table of content: (NPI 1316281637)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316281637 NPI number — EVOLUTION CHIROPRACTIC, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVOLUTION CHIROPRACTIC, P.A.
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:
6
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:
1316281637
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8120 PENN AVE S
Provider Second Line Business Mailing Address:
SUITE 444
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55431-1358
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-270-5374
Provider Business Mailing Address Fax Number:
952-223-6153

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8120 PENN AVE S
Provider Second Line Business Practice Location Address:
SUITE 444
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55431-1358
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-270-5374
Provider Business Practice Location Address Fax Number:
952-223-6153
Provider Enumeration Date:
11/27/2012

Additional Information

Authorized Official

Authorized Official Last Name:
DORPINGHAUS
Authorized Official First Name:
JODI
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
CHIROPRACTOR/OWNER
Authorized Official Telephone Number:
952-564-6452

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  5117 , 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: 1285800748 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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