Healthcare Provider Details

I. General information

NPI: 1770638520
Provider Name (Legal Business Name): JOHN ROBERT PIETILA D.C., D.A.C.N.B.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 08/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12376 RIVER RIDGE BLVD
BURNSVILLE MN
55337-1665
US

IV. Provider business mailing address

12358 RIVER RIDGE BLVD
BURNSVILLE MN
55337-1665
US

V. Phone/Fax

Practice location:
  • Phone: 952-808-0987
  • Fax: 952-808-0986
Mailing address:
  • Phone: 952-681-7746
  • Fax: 952-681-7654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number4304
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: