Healthcare Provider Details

I. General information

NPI: 1366712739
Provider Name (Legal Business Name): ZACHARY ROBERT SUNDBERG D.C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2012
Last Update Date: 01/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4221 WINNETKA AVE N
NEW HOPE MN
55428-4924
US

IV. Provider business mailing address

4221 WINNETKA AVE N
NEW HOPE MN
55428-4924
US

V. Phone/Fax

Practice location:
  • Phone: 763-533-0654
  • Fax: 763-537-5305
Mailing address:
  • Phone: 763-533-0654
  • Fax: 763-537-5305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5615
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: