Healthcare Provider Details

I. General information

NPI: 1194809863
Provider Name (Legal Business Name): CANNON VALLEY CHIROPRACTIC,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6505 CEDAR HILLS DR
CANNON FALLS MN
55009-4253
US

IV. Provider business mailing address

6505 CEDAR HILLS DR
CANNON FALLS MN
55009-4253
US

V. Phone/Fax

Practice location:
  • Phone: 507-263-3925
  • Fax: 507-263-5065
Mailing address:
  • Phone: 507-263-3925
  • Fax: 507-263-5065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number4074
License Number StateMN

VIII. Authorized Official

Name: DR. MATTHEW AUGUST MAKI
Title or Position: OWNER/DOCTOR
Credential: D.C.
Phone: 507-263-3925