Healthcare Provider Details

I. General information

NPI: 1710894902
Provider Name (Legal Business Name): HOMEGROWN CHIROPRACTIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 15TH AVE S STE 104
FARGO ND
58103-8956
US

IV. Provider business mailing address

4501 15TH AVE S STE 104
FARGO ND
58103-8956
US

V. Phone/Fax

Practice location:
  • Phone: 701-532-0541
  • Fax:
Mailing address:
  • Phone: 701-532-0541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. TAYLOR JON PTACEK
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 701-710-0365