Provider Demographics
NPI:1063653202
Name:TELIC FAMILY CHIROPRACTIC PA
Entity Type:Organization
Organization Name:TELIC FAMILY CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:TRAPPER
Authorized Official - Last Name:KUECHER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-828-4166
Mailing Address - Street 1:19157 SODER ROAD
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401
Mailing Address - Country:US
Mailing Address - Phone:218-828-4166
Mailing Address - Fax:218-828-4496
Practice Address - Street 1:19157 SODER ROAD
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401
Practice Address - Country:US
Practice Address - Phone:218-828-4166
Practice Address - Fax:218-828-4496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-18
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN714111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC04337Medicare PIN