Provider Demographics
NPI:1790735488
Name:REQUET, EDWARD LESLIE (DC)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:LESLIE
Last Name:REQUET
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 MARKET STREET
Mailing Address - Street 2:SUITE 260
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317
Mailing Address - Country:US
Mailing Address - Phone:952-975-2959
Mailing Address - Fax:952-975-2973
Practice Address - Street 1:600 MARKET STREET
Practice Address - Street 2:SUITE 260 REQUET CHIROPRACTIC WELLNESS CENTER
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317
Practice Address - Country:US
Practice Address - Phone:952-975-2959
Practice Address - Fax:952-975-2973
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN3177111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4C666REOtherBLUE CROSS
MN359000335Medicare ID - Type Unspecified
U47654Medicare UPIN