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General NPI Number Information
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NPI Number | 1588611438
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Entity Type | Organization
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Legal Business Name | MARTY CLINIC PA
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Dates
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Enumeration Date | 05/27/2006
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Last Update Date | 06/08/2009
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Provider Practice Location Address
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Address Line | 5201 EDEN AVE SUITE 190
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City | EDINA
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State | MN
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Zip | 55436-2316
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Country | US
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Telephone | 952-920-9721
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Fax | 952-241-4355
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Provider Business Mailing Address
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Address Line | 5201 EDEN AVE SUITE 190
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City | EDINA
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State | MN
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Zip | 55436-2316
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Country | US
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Telephone | 952-920-9721
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Fax | 952-241-4355
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | SUSAN MARTYELDRIDGE
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Credential | D.C.
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Telephone | 952-920-9721
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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 | 1566
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License Number State | MN
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