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General NPI Number Information
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NPI Number | 1316115934
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Entity Type | Organization
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Legal Business Name | PETTIS CHIROPRACTIC
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Dates
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Enumeration Date | 02/16/2008
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Last Update Date | 06/19/2008
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Provider Practice Location Address
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Address Line | 1570 CENTURY PT
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City | EAGAN
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State | MN
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Zip | 55121-1926
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Country | US
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Telephone | 651-261-1923
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Fax | 651-405-6627
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Provider Business Mailing Address
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Address Line | 1570 CENTURY PT
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City | EAGAN
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State | MN
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Zip | 55121-1926
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Country | US
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Telephone | 651-261-1923
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Fax | 651-405-6627
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Authorized Official
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Title or Position | OWNER/CHIROPRACTOR
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Name | JAY PETTIS
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Credential | D.C.
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Telephone | 651-261-1923
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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 | 4807
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License Number State | MN
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