=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568925097
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2019
-----------------------------------------------------
Last Update Date | 09/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 123 LAFAYETTE AVE SW
-----------------------------------------------------
City | EYOTA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55934-6507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-797-8138
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 57
-----------------------------------------------------
City | EYOTA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55934-0057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-585-0528
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | MARK WESTPHAL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 608-797-8138
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NN1001X
-----------------------------------------------------
Taxonomy Name | Nutrition Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------