Provider Demographics
NPI:1003830787
Name:MARTY CHIROPRACTIC-EXCELSIOR INC
Entity Type:Organization
Organization Name:MARTY CHIROPRACTIC-EXCELSIOR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CHIEF EXECUTIVE OFFICIE
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:MARTY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-474-4121
Mailing Address - Street 1:464 SECOND STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331
Mailing Address - Country:US
Mailing Address - Phone:952-474-4121
Mailing Address - Fax:952-474-8391
Practice Address - Street 1:464 SECOND STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331
Practice Address - Country:US
Practice Address - Phone:952-474-4121
Practice Address - Fax:952-474-8391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN10872MAOtherBCBS
MN10872MAOtherBCBS