1346236627 NPI number — BENDER FAMILY CHIROPRACTIC PLLC

Table of content: DOMINQUE LACATHERINE SHIELDS APRN CNP (NPI 1720586423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346236627 NPI number — BENDER FAMILY CHIROPRACTIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BENDER FAMILY CHIROPRACTIC PLLC
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:
1346236627
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:
119 GRAYSTONE PLAZA
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
DETROIT LAKES
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-847-2631
Provider Business Mailing Address Fax Number:
218-847-0048

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 GRAYSTONE PLAZA
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
DETROIT LAKES
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-847-2631
Provider Business Practice Location Address Fax Number:
218-847-0048
Provider Enumeration Date:
09/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BENDER
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
218-847-2631

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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