Healthcare Provider Details

I. General information

NPI: 1235150905
Provider Name (Legal Business Name): PAYNESVILLE CHIROPRACTIC CLINIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 09/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 E HIGHWAY 55
PAYNESVILLE MN
56362-2047
US

IV. Provider business mailing address

319 E HIGHWAY 55
PAYNESVILLE MN
56362-2047
US

V. Phone/Fax

Practice location:
  • Phone: 320-243-7551
  • Fax: 320-243-7571
Mailing address:
  • Phone: 320-243-7551
  • Fax: 320-243-7571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3023
License Number StateMN

VIII. Authorized Official

Name: DR. ELIZABETH PAULINE GREGUSON-PUPPE
Title or Position: OWNER
Credential: D.C.
Phone: 320-243-7551