Provider Demographics
NPI:1578041471
Name:RESTORATION CHIROPRACTIC COMPANY, P.A.
Entity Type:Organization
Organization Name:RESTORATION CHIROPRACTIC COMPANY, P.A.
Other - Org Name:OMEGA CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IAN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:MCCANN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-574-5020
Mailing Address - Street 1:2675 W 78TH ST
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-4502
Mailing Address - Country:US
Mailing Address - Phone:952-474-1544
Mailing Address - Fax:952-474-1545
Practice Address - Street 1:2675 W 78TH ST
Practice Address - Street 2:
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-4502
Practice Address - Country:US
Practice Address - Phone:952-474-1544
Practice Address - Fax:952-474-1545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6154111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty