Provider Demographics
NPI:1417540774
Name:PEQUOT LAKES CHIROPRACTIC PA
Entity Type:Organization
Organization Name:PEQUOT LAKES CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:DIETZE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-568-7677
Mailing Address - Street 1:PO BOX 281
Mailing Address - Street 2:
Mailing Address - City:PEQUOT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56472-0241
Mailing Address - Country:US
Mailing Address - Phone:218-568-7767
Mailing Address - Fax:218-568-4580
Practice Address - Street 1:31095 BERQUIST DR
Practice Address - Street 2:
Practice Address - City:PEQUOT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56472-5647
Practice Address - Country:US
Practice Address - Phone:218-568-7767
Practice Address - Fax:218-568-4580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty