Provider Demographics
NPI:1558577932
Name:DENVER CHIROPRACTIC PA
Entity Type:Organization
Organization Name:DENVER CHIROPRACTIC PA
Other - Org Name:DENVER CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER,CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:EMIL
Authorized Official - Last Name:DENVER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-326-0071
Mailing Address - Street 1:107 SE 10TH ST
Mailing Address - Street 2:P.O. BOX 908
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3914
Mailing Address - Country:US
Mailing Address - Phone:218-326-0071
Mailing Address - Fax:218-327-1999
Practice Address - Street 1:107 SE 10TH ST
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3914
Practice Address - Country:US
Practice Address - Phone:218-326-0071
Practice Address - Fax:218-327-1999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2456111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN687695200Medicaid
MN350003471Medicare UPIN
MNC04072Medicare PIN