Provider Demographics
NPI:1235597014
Name:FARIBAULT WELLNESS CENTER, P.A.
Entity Type:Organization
Organization Name:FARIBAULT WELLNESS CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROMANIE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:757-277-4844
Mailing Address - Street 1:120 CENTRAL AVE N
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-5211
Mailing Address - Country:US
Mailing Address - Phone:757-277-4844
Mailing Address - Fax:
Practice Address - Street 1:120 CENTRAL AVE N
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-5211
Practice Address - Country:US
Practice Address - Phone:757-277-4844
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3914111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty