Provider Demographics
NPI:1952484602
Name:JO G THEISEN DC, PA
Entity Type:Organization
Organization Name:JO G THEISEN DC, PA
Other - Org Name:FAMILY CHIROPRACTIC HEALTH SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:R
Authorized Official - Last Name:THEISEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-424-7750
Mailing Address - Street 1:8465 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55445-2266
Mailing Address - Country:US
Mailing Address - Phone:763-424-7750
Mailing Address - Fax:763-424-3444
Practice Address - Street 1:8465 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55445-2266
Practice Address - Country:US
Practice Address - Phone:763-424-7750
Practice Address - Fax:763-424-3444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2599111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC04402Medicare ID - Type UnspecifiedMC FACILITY LEVEL ID