Provider Demographics
NPI:1659873420
Name:RESTORE CHIROPRACTIC AND WELLNESS LLC
Entity Type:Organization
Organization Name:RESTORE CHIROPRACTIC AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMMA
Authorized Official - Middle Name:J
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-994-8595
Mailing Address - Street 1:PO BOX 226
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MN
Mailing Address - Zip Code:55334-0226
Mailing Address - Country:US
Mailing Address - Phone:952-994-8595
Mailing Address - Fax:
Practice Address - Street 1:215 3RD ST
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MN
Practice Address - Zip Code:55334
Practice Address - Country:US
Practice Address - Phone:507-237-2777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-07
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5968111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1346649126Medicaid