Provider Demographics
NPI:1114114642
Name:INNATE & HYACK FAMILY CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:INNATE & HYACK FAMILY CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:HYACK
Authorized Official - Suffix:
Authorized Official - Credentials:DC, BS
Authorized Official - Phone:952-854-0057
Mailing Address - Street 1:2626 E 82ND ST
Mailing Address - Street 2:#103
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1300
Mailing Address - Country:US
Mailing Address - Phone:952-854-0057
Mailing Address - Fax:952-854-0058
Practice Address - Street 1:2626 E 82ND ST
Practice Address - Street 2:#103
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-1300
Practice Address - Country:US
Practice Address - Phone:952-854-0057
Practice Address - Fax:952-854-0058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4518111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC04123OtherMEDICARE GROUP #