Provider Demographics
NPI:1063853166
Name:KINGSWAY CHIROPRACTIC, PA
Entity Type:Organization
Organization Name:KINGSWAY CHIROPRACTIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:FENSKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:612-432-8558
Mailing Address - Street 1:17595 KENWOOD TRL
Mailing Address - Street 2:SUITE 190
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-9226
Mailing Address - Country:US
Mailing Address - Phone:952-898-5929
Mailing Address - Fax:952-898-5959
Practice Address - Street 1:17595 KENWOOD TRL
Practice Address - Street 2:SUITE 190
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-9226
Practice Address - Country:US
Practice Address - Phone:952-898-5929
Practice Address - Fax:952-898-5959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4523261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center