Healthcare Provider Details

I. General information

NPI: 1427186907
Provider Name (Legal Business Name): DYNAMIC FAMILY CHIROPRACTIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4739 COUNTY ROAD 101
MINNETONKA MN
55345-2634
US

IV. Provider business mailing address

4739 COUNTY ROAD 101
MINNETONKA MN
55345-2634
US

V. Phone/Fax

Practice location:
  • Phone: 952-933-2695
  • Fax: 952-933-2763
Mailing address:
  • Phone: 952-933-2695
  • Fax: 952-933-2763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3475
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number4012
License Number StateMN

VIII. Authorized Official

Name: MR. ANDREW E. LUING
Title or Position: OWNER
Credential:
Phone: 952-933-2695