Provider Demographics
NPI:1205144722
Name:PEDDYCOART CHIROPRACTIC INC.
Entity type:Organization
Organization Name:PEDDYCOART CHIROPRACTIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENWYN
Authorized Official - Middle Name:ANNE-LISA
Authorized Official - Last Name:PEDDYCOART
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-770-8424
Mailing Address - Street 1:1803 BUERKLE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-5269
Mailing Address - Country:US
Mailing Address - Phone:651-770-8424
Mailing Address - Fax:651-770-3170
Practice Address - Street 1:1803 BUERKLE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-5269
Practice Address - Country:US
Practice Address - Phone:651-770-8424
Practice Address - Fax:651-770-3170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-17
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3350111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty