Provider Demographics
NPI:1083081418
Name:DETTLING CHIROPRACTIC REHAB AND PERFORMANCE PLLC
Entity Type:Organization
Organization Name:DETTLING CHIROPRACTIC REHAB AND PERFORMANCE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ HEAD DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:DETTLING
Authorized Official - Suffix:
Authorized Official - Credentials:DC MS
Authorized Official - Phone:763-560-8980
Mailing Address - Street 1:615 66TH AVE N STE 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-1666
Mailing Address - Country:US
Mailing Address - Phone:763-560-8980
Mailing Address - Fax:763-560-0611
Practice Address - Street 1:615 66TH AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-1667
Practice Address - Country:US
Practice Address - Phone:763-560-8980
Practice Address - Fax:763-560-0611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-02
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6125111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty