=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063696540
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLS CHIROPRACTIC CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2007
-----------------------------------------------------
Last Update Date | 11/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 N GROVE ST
-----------------------------------------------------
City | BLUE EARTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56013-2407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-526-5656
-----------------------------------------------------
Fax | 507-526-5757
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 N GROVE ST
-----------------------------------------------------
City | BLUE EARTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56013-2407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-526-5656
-----------------------------------------------------
Fax | 507-526-5757
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CHAD A MALWITZ
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 507-526-5656
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3445
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------