Provider Demographics
NPI:1669763827
Name:BREWER CORP PA
Entity type:Organization
Organization Name:BREWER CORP PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-471-2555
Mailing Address - Street 1:3800 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-9785
Mailing Address - Country:US
Mailing Address - Phone:952-471-2555
Mailing Address - Fax:952-471-2556
Practice Address - Street 1:3800 SHORELINE DR.
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-9785
Practice Address - Country:US
Practice Address - Phone:952-471-2555
Practice Address - Fax:952-471-2556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-22
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2026111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
350002493Medicare UPIN