Healthcare Provider Details

I. General information

NPI: 1073569927
Provider Name (Legal Business Name): PLYMOUTH GROVE CHIROPRACTIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 VINEWOOD LN N SUITE 19
PLYMOUTH MN
55441-1155
US

IV. Provider business mailing address

3900 VINEWOOD LN N SUITE 19
PLYMOUTH MN
55441-1155
US

V. Phone/Fax

Practice location:
  • Phone: 763-559-9236
  • Fax: 763-559-7486
Mailing address:
  • Phone: 763-559-9236
  • Fax: 763-559-7486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number280
License Number StateMN

VIII. Authorized Official

Name: DR. VIVI-ANN RAE FISCHER
Title or Position: PRESIDENT
Credential: D.C.
Phone: 763-559-9236