Provider Demographics
NPI:1851525893
Name:DEHAVEN CHIROPRACTIC CLINIC, INC
Entity Type:Organization
Organization Name:DEHAVEN CHIROPRACTIC CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:K
Authorized Official - Last Name:DEHAVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-429-3015
Mailing Address - Street 1:20681 JULY AVE N
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-9173
Mailing Address - Country:US
Mailing Address - Phone:651-429-3015
Mailing Address - Fax:
Practice Address - Street 1:4505 WHITE BEAR PKWY STE 2200
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3699
Practice Address - Country:US
Practice Address - Phone:651-429-3015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-05
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2585111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN59969-DEOtherBCBS