Provider Demographics
NPI:1578943791
Name:PETERNELL CHIROPRACTIC PC
Entity Type:Organization
Organization Name:PETERNELL CHIROPRACTIC PC
Other - Org Name:COLD SPRING SPINE AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:320-761-2525
Mailing Address - Street 1:24 3RD AVE S
Mailing Address - Street 2:SUITE 4
Mailing Address - City:COLD SPRING
Mailing Address - State:MN
Mailing Address - Zip Code:56320-4544
Mailing Address - Country:US
Mailing Address - Phone:320-686-0137
Mailing Address - Fax:
Practice Address - Street 1:24 3RD AVE S
Practice Address - Street 2:SUITE 4
Practice Address - City:COLD SPRING
Practice Address - State:MN
Practice Address - Zip Code:56320-4544
Practice Address - Country:US
Practice Address - Phone:320-686-0137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6092111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty