Healthcare Provider Details

I. General information

NPI: 1598875171
Provider Name (Legal Business Name): FAMILY CHIROPRACTIC OF WARREN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 N MAIN STREET
WARREN MN
56762
US

IV. Provider business mailing address

603 N MAIN STREET
WARREN MN
56762
US

V. Phone/Fax

Practice location:
  • Phone: 218-745-6655
  • Fax: 218-745-4049
Mailing address:
  • Phone: 218-745-6655
  • Fax: 218-745-4049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3351
License Number StateMN

VIII. Authorized Official

Name: DR. MARK ALAN PEDERSON
Title or Position: DOCTOR
Credential: DC
Phone: 218-745-6655