Provider Demographics
NPI:1235223694
Name:PERREAULT CHIROPRACTIC
Entity Type:Organization
Organization Name:PERREAULT CHIROPRACTIC
Other - Org Name:ROGER E PERREAULT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:E
Authorized Official - Last Name:PERREAULT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:320-325-3441
Mailing Address - Street 1:P O BOX 86
Mailing Address - Street 2:263 W 4TH ST
Mailing Address - City:RUSH CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55069
Mailing Address - Country:US
Mailing Address - Phone:320-358-3441
Mailing Address - Fax:320-358-3624
Practice Address - Street 1:263 W 4TH ST
Practice Address - Street 2:
Practice Address - City:RUSH CITY
Practice Address - State:MN
Practice Address - Zip Code:55069
Practice Address - Country:US
Practice Address - Phone:320-358-3441
Practice Address - Fax:320-358-3624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1666111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN230668OtherCHIROPRACTIC CARE OF MN
MN1D067PEOtherBLUE CROSS/BLUE SHIELD
MN1D067PEOtherBLUE CROSS/BLUE SHIELD