Healthcare Provider Details

I. General information

NPI: 1790735488
Provider Name (Legal Business Name): EDWARD LESLIE REQUET DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 MARKET STREET SUITE 260 REQUET CHIROPRACTIC WELLNESS CENTER
CHANHASSEN MN
55317
US

IV. Provider business mailing address

600 MARKET STREET SUITE 260
CHANHASSEN MN
55317
US

V. Phone/Fax

Practice location:
  • Phone: 952-975-2959
  • Fax: 952-975-2973
Mailing address:
  • Phone: 952-975-2959
  • Fax: 952-975-2973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberMN3177
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: