Provider Demographics
NPI:1598875171
Name:FAMILY CHIROPRACTIC OF WARREN INC
Entity Type:Organization
Organization Name:FAMILY CHIROPRACTIC OF WARREN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:PEDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-745-6655
Mailing Address - Street 1:603 N MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MN
Mailing Address - Zip Code:56762
Mailing Address - Country:US
Mailing Address - Phone:218-745-6655
Mailing Address - Fax:218-745-4049
Practice Address - Street 1:603 N MAIN STREET
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MN
Practice Address - Zip Code:56762
Practice Address - Country:US
Practice Address - Phone:218-745-6655
Practice Address - Fax:218-745-4049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3351111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND20215OtherBCBS
MN15F41PEOtherBCBS
MN15F41PEOtherBCBS