Provider Demographics
NPI:1790882785
Name:DEEPHAVEN CHIROPRACTIC, P.A.
Entity Type:Organization
Organization Name:DEEPHAVEN CHIROPRACTIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:LOVE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-475-0079
Mailing Address - Street 1:18281 MINNETONKA BLVD
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-3345
Mailing Address - Country:US
Mailing Address - Phone:952-475-0079
Mailing Address - Fax:952-475-1030
Practice Address - Street 1:18281 MINNETONKA BLVD
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-3345
Practice Address - Country:US
Practice Address - Phone:952-475-0079
Practice Address - Fax:952-475-1030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3658111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU82339OtherMETROPOLITAN HEALTH PLAN
MN60B90DEOtherBCBS
MN60B90DEOtherBCBS
MNU82339OtherMETROPOLITAN HEALTH PLAN