Provider Demographics
NPI:1578850061
Name:WURDEMANN CHIROPRACTIC PA
Entity Type:Organization
Organization Name:WURDEMANN CHIROPRACTIC PA
Other - Org Name:REVIVE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:WURDEMANN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-674-2700
Mailing Address - Street 1:6368 ELM STREET
Mailing Address - Street 2:
Mailing Address - City:NORTH BRANCH
Mailing Address - State:MN
Mailing Address - Zip Code:55056-0094
Mailing Address - Country:US
Mailing Address - Phone:651-674-2700
Mailing Address - Fax:651-674-4135
Practice Address - Street 1:6272 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH BRANCH
Practice Address - State:MN
Practice Address - Zip Code:55056-6593
Practice Address - Country:US
Practice Address - Phone:651-674-2700
Practice Address - Fax:651-674-4135
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WURDEMANN CHIROPRACTIC PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-05
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1518251685OtherNPI FOR INDIVIDUAL - DR. PETER WURDEMANN