Provider Demographics
NPI:1982273041
Name:FAUTSCH, ANDREW (DC)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:FAUTSCH
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 1:12670 BASS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-6380
Mailing Address - Country:US
Mailing Address - Phone:877-442-4476
Mailing Address - Fax:
Practice Address - Street 1:12670 BASS LAKE RD
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-6380
Practice Address - Country:US
Practice Address - Phone:877-442-4476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN128031111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty