Provider Demographics
NPI:1508045055
Name:DONNER FAMILY CHIROPRACTIC PA
Entity Type:Organization
Organization Name:DONNER FAMILY CHIROPRACTIC PA
Other - Org Name:PAULY CHIROPRACTIC CENTER PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:DONNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:320-235-8380
Mailing Address - Street 1:412 19TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-5297
Mailing Address - Country:US
Mailing Address - Phone:320-235-8380
Mailing Address - Fax:320-235-8381
Practice Address - Street 1:412 19TH AVE SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-5297
Practice Address - Country:US
Practice Address - Phone:320-235-8380
Practice Address - Fax:320-235-8381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1687111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN332727200Medicaid
MN755007OtherOPTUM HEALTH
MN43232PAOtherBCBS
MN350046462OtherRR MEDICARE
MNC03815OtherMEDICARE
MNT65972Medicare UPIN