Healthcare Provider Details

I. General information

NPI: 1609007202
Provider Name (Legal Business Name): KAVANAGH CHIROPRACTIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2009
Last Update Date: 07/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 110TH AVE SE
DE GRAFF MN
56271-9071
US

IV. Provider business mailing address

500 MARSCHALL ROAD SUITE 130
SHAKOPEE MN
55379-2693
US

V. Phone/Fax

Practice location:
  • Phone: 612-590-3899
  • Fax: 952-445-9313
Mailing address:
  • Phone: 952-445-9313
  • Fax: 952-445-9313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4998
License Number StateMN

VIII. Authorized Official

Name: DR. SARAH JEAN KAVANAGH
Title or Position: PRESIDENT
Credential: D.C.
Phone: 952-445-9313