=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184922387
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AFFINITY CHIROPRACTIC LLCQ
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2011
-----------------------------------------------------
Last Update Date | 03/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5100 THIMSEN AVE STE 200
-----------------------------------------------------
City | MINNETONKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55345-4160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-564-5051
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5100 THIMSEN AVE STE 200
-----------------------------------------------------
City | MINNETONKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55345-4160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-564-5051
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR OF CHIROPRACTIC
-----------------------------------------------------
Name | DR. MICHAEL PHILIP KOMRO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 612-564-5051
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 5430
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------