Provider Demographics
NPI:1669527636
Name:PENNEBAKER CLINIC OF CHIROPRACTIC,LLC
Entity type:Organization
Organization Name:PENNEBAKER CLINIC OF CHIROPRACTIC,LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCNEIL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-941-2225
Mailing Address - Street 1:8140 FLYING CLOUD DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5364
Mailing Address - Country:US
Mailing Address - Phone:952-941-2225
Mailing Address - Fax:952-903-2816
Practice Address - Street 1:12300 SINGLETREE LN STE 200
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-7964
Practice Address - Country:US
Practice Address - Phone:952-941-2225
Practice Address - Fax:952-903-2816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1392111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty