Provider Demographics
NPI:1073617320
Name:EDWARD L REQUET DC PA
Entity Type:Organization
Organization Name:EDWARD L REQUET DC PA
Other - Org Name:REQUET CHIROPRACTIC WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:LESLIE
Authorized Official - Last Name:REQUET
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-975-2959
Mailing Address - Street 1:600 MARKET ST
Mailing Address - Street 2:SUITE 260
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317
Mailing Address - Country:US
Mailing Address - Phone:952-975-2959
Mailing Address - Fax:952-975-2973
Practice Address - Street 1:600 MARKET ST
Practice Address - Street 2:SUITE 260 REQUET CHIROPRACTIC WELLNESS CENTER
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317
Practice Address - Country:US
Practice Address - Phone:952-975-2959
Practice Address - Fax:952-975-2973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN3177111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4C665REOtherBLUE CROSS
MN4C666REOtherBLUE CROSS
MN4C666REOtherBLUE CROSS
U47654Medicare UPIN