Provider Demographics
NPI:1538481734
Name:FAMILY CHIROPRACTIC OF SHAKOPEE, P.A.
Entity Type:Organization
Organization Name:FAMILY CHIROPRACTIC OF SHAKOPEE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LESLIE
Authorized Official - Last Name:HARDER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-445-0679
Mailing Address - Street 1:1221 4TH AVE E
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-1681
Mailing Address - Country:US
Mailing Address - Phone:952-445-0679
Mailing Address - Fax:952-445-6979
Practice Address - Street 1:1221 4TH AVE E
Practice Address - Street 2:SUITE 120
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-1681
Practice Address - Country:US
Practice Address - Phone:952-445-0679
Practice Address - Fax:952-445-6979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-16
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3128111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN512718100Medicaid
MN4C223FAOtherBCBS PROVIDER CLINIC NO
MN4C223FAOtherBCBS PROVIDER CLINIC NO