Provider Demographics
NPI:1801033931
Name:MANKATO CHIROPRACTIC RIVER'S EDGE
Entity Type:Organization
Organization Name:MANKATO CHIROPRACTIC RIVER'S EDGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:507-345-4035
Mailing Address - Street 1:1900 N SUNRISE DR
Mailing Address - Street 2:STE 100
Mailing Address - City:SAINT PETER
Mailing Address - State:MN
Mailing Address - Zip Code:56082-5376
Mailing Address - Country:US
Mailing Address - Phone:507-345-4035
Mailing Address - Fax:507-345-4122
Practice Address - Street 1:1900 N SUNRISE DR
Practice Address - Street 2:STE 100
Practice Address - City:SAINT PETER
Practice Address - State:MN
Practice Address - Zip Code:56082-5376
Practice Address - Country:US
Practice Address - Phone:507-345-4035
Practice Address - Fax:507-345-4122
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MANKATO CHIROPRACTIC CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-12
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3058111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty