Provider Demographics
NPI:1922541044
Name:PERREAULT CHIROPRACTIC AND ACUPUNCTURE SERVICE CORPORATION
Entity Type:Organization
Organization Name:PERREAULT CHIROPRACTIC AND ACUPUNCTURE SERVICE CORPORATION
Other - Org Name:PERREAULT CHIROPRACTIC & ACUPUNCTURE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PERREAULT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-674-4833
Mailing Address - Street 1:6361 MAIN ST
Mailing Address - Street 2:PO BOX 782
Mailing Address - City:NORTH BRANCH
Mailing Address - State:MN
Mailing Address - Zip Code:55056-6693
Mailing Address - Country:US
Mailing Address - Phone:651-674-4833
Mailing Address - Fax:651-674-5847
Practice Address - Street 1:6361 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH BRANCH
Practice Address - State:MN
Practice Address - Zip Code:55056-6693
Practice Address - Country:US
Practice Address - Phone:651-674-4833
Practice Address - Fax:651-674-5847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-21
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4230111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN065880400Medicaid
1699711614OtherINDIVIDUAL NPI