Provider Demographics
NPI:1043761133
Name:MARTY CHIROPRACTIC & WELLNESS LLC
Entity Type:Organization
Organization Name:MARTY CHIROPRACTIC & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:GLEN
Authorized Official - Last Name:MARTY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:612-440-5776
Mailing Address - Street 1:18476 KENRICK AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-9288
Mailing Address - Country:US
Mailing Address - Phone:612-440-5776
Mailing Address - Fax:952-236-6732
Practice Address - Street 1:18476 KENRICK AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-9288
Practice Address - Country:US
Practice Address - Phone:612-440-5776
Practice Address - Fax:952-236-6732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6189111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty