=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427186907
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DYNAMIC FAMILY CHIROPRACTIC PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2007
-----------------------------------------------------
Last Update Date | 03/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4739 COUNTY ROAD 101
-----------------------------------------------------
City | MINNETONKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55345-2634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-933-2695
-----------------------------------------------------
Fax | 952-933-2763
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4739 COUNTY ROAD 101
-----------------------------------------------------
City | MINNETONKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55345-2634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-933-2695
-----------------------------------------------------
Fax | 952-933-2763
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ANDREW E. LUING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 952-933-2695
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number | 4012
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3475
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------