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General NPI Number Information
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NPI Number | 1043761133
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Entity Type | Organization
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Legal Business Name | MARTY CHIROPRACTIC & WELLNESS LLC
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Dates
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Enumeration Date | 10/24/2016
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Last Update Date | 10/24/2016
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Provider Practice Location Address
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Address Line | 18476 KENRICK AVE SUITE 201
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City | LAKEVILLE
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State | MN
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Zip | 55044-9288
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Country | US
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Telephone | 612-440-5776
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Fax | 952-236-6732
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Provider Business Mailing Address
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Address Line | 18476 KENRICK AVE SUITE 201
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City | LAKEVILLE
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State | MN
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Zip | 55044-9288
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Country | US
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Telephone | 612-440-5776
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Fax | 952-236-6732
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Authorized Official
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Title or Position | OWNER/CHIROPRACTOR
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Name | DR. JEREMY GLEN MARTY
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Credential | D.C.
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Telephone | 612-440-5776
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 6189
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License Number State | MN
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