Provider Demographics
NPI:1780761395
Name:RENWICK, CHAD DANIEL (DC)
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:DANIEL
Last Name:RENWICK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13786 FRONTIER CT STE 100
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4832
Mailing Address - Country:US
Mailing Address - Phone:952-891-1955
Mailing Address - Fax:952-891-1483
Practice Address - Street 1:13786 FRONTIER CT STE 100
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4832
Practice Address - Country:US
Practice Address - Phone:952-891-1955
Practice Address - Fax:952-891-1483
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3401111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN674222000Medicaid
MN84D20BUOtherBXBS
MN84D20BUOtherBXBS
MN674222000Medicaid