=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174254437
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PURA VIDA CHIROPRACTIC & WELLNESS, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2022
-----------------------------------------------------
Last Update Date | 09/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 403 W BURNSVILLE PKWY
-----------------------------------------------------
City | BURNSVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55337-2569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-895-4085
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 403 W BURNSVILLE PKWY
-----------------------------------------------------
City | BURNSVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55337-2569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-895-4085
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR OF CHIROPRACTIC
-----------------------------------------------------
Name | DR. EMILY QUAST
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 612-708-1638
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------