Healthcare Provider Details

I. General information

NPI: 1245203751
Provider Name (Legal Business Name): JEFFREY ALAN GRUNST D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 BRYANT AVE SE
WADENA MN
56482-1544
US

IV. Provider business mailing address

10 BRYANT AVE SE
WADENA MN
56482-1544
US

V. Phone/Fax

Practice location:
  • Phone: 218-631-3382
  • Fax: 218-631-3479
Mailing address:
  • Phone: 218-631-3382
  • Fax: 218-631-3479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2831
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: