Provider Demographics
NPI:1427204650
Name:CHIROPRACTIC WELLNESS INNOVATIONS PLLC
Entity Type:Organization
Organization Name:CHIROPRACTIC WELLNESS INNOVATIONS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:J
Authorized Official - Last Name:DESHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:319-350-5330
Mailing Address - Street 1:1590 THOMAS CENTER DR STE 110
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-5406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1590 THOMAS CENTER DR STE 110
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-5406
Practice Address - Country:US
Practice Address - Phone:651-209-9710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty