Provider Demographics
NPI:1679995427
Name:PENNEY FAMILY CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:PENNEY FAMILY CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HOLLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-492-5253
Mailing Address - Street 1:401 BROADWAY ST S
Mailing Address - Street 2:
Mailing Address - City:JORDAN
Mailing Address - State:MN
Mailing Address - Zip Code:55352-1701
Mailing Address - Country:US
Mailing Address - Phone:952-492-5253
Mailing Address - Fax:952-456-6966
Practice Address - Street 1:401 BROADWAY ST S
Practice Address - Street 2:
Practice Address - City:JORDAN
Practice Address - State:MN
Practice Address - Zip Code:55352-1701
Practice Address - Country:US
Practice Address - Phone:952-492-5253
Practice Address - Fax:952-456-6966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-14
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN350005279Medicare PIN