Healthcare Provider Details

I. General information

NPI: 1700934429
Provider Name (Legal Business Name): SOUTHWEST CHIROPRACTIC CLINIC OF WORTHINGTON, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 DIAGONAL RD
WORTHINGTON MN
56187-1114
US

IV. Provider business mailing address

1301 DIAGONAL RD
WORTHINGTON MN
56187-1114
US

V. Phone/Fax

Practice location:
  • Phone: 507-376-9663
  • Fax: 507-376-9663
Mailing address:
  • Phone: 507-376-9663
  • Fax: 507-376-9663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4388
License Number StateMN

VIII. Authorized Official

Name: DR. JACOB JOHN ROETHLER
Title or Position: PRESIDENT, CHIROPRACTOR
Credential: D.C.
Phone: 507-376-9663