Provider Demographics
NPI:1336587864
Name:RENA A. WIDBOOM, PLLC
Entity Type:Organization
Organization Name:RENA A. WIDBOOM, PLLC
Other - Org Name:ENCOMPASS CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RENA
Authorized Official - Middle Name:A
Authorized Official - Last Name:WIDBOOM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-559-5326
Mailing Address - Street 1:13605 27TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-3616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13605 27TH AVE N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-3616
Practice Address - Country:US
Practice Address - Phone:763-559-5326
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5145111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty