Provider Demographics
NPI:1043929813
Name:EDEN PRAIRIE CHIROPRACTIC CLINIC INC
Entity Type:Organization
Organization Name:EDEN PRAIRIE CHIROPRACTIC CLINIC INC
Other - Org Name:EDEN PRAIRIE CHIROCENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:ALLENBURG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-212-7489
Mailing Address - Street 1:7820 TERREY PINE CT STE 102
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347-1107
Mailing Address - Country:US
Mailing Address - Phone:952-937-1226
Mailing Address - Fax:
Practice Address - Street 1:7820 TERREY PINE CT STE 102
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55347-1107
Practice Address - Country:US
Practice Address - Phone:952-937-1226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-21
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty