Provider Demographics
NPI:1811107667
Name:PACOVSKY, FREDRICK PAUL (DC)
Entity type:Individual
Prefix:
First Name:FREDRICK
Middle Name:PAUL
Last Name:PACOVSKY
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 1:13550 26TH AVE N STE 300
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-3650
Mailing Address - Country:US
Mailing Address - Phone:763-557-0101
Mailing Address - Fax:763-557-0828
Practice Address - Street 1:13550 26TH AVE N STE 300
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-3650
Practice Address - Country:US
Practice Address - Phone:763-557-0101
Practice Address - Fax:763-557-0828
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2676111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNPF0282Medicare ID - Type Unspecified
MNT85022Medicare UPIN