Healthcare Provider Details

I. General information

NPI: 1043506454
Provider Name (Legal Business Name): ANDOVER FAMILY CHIROPRACTIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 06/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1573 154TH AVE NW
ANDOVER MN
55304-2695
US

IV. Provider business mailing address

1573 154TH AVE NW
ANDOVER MN
55304-2695
US

V. Phone/Fax

Practice location:
  • Phone: 763-413-0032
  • Fax: 763-432-3688
Mailing address:
  • Phone: 763-413-0032
  • Fax: 763-432-3688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: DAVID HENNING
Title or Position: PRESIDENT
Credential: DC
Phone: 763-957-2940