=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710337167
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE WELLNESS WAY COTTAGE GROVE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2016
-----------------------------------------------------
Last Update Date | 06/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7145 E POINT DOUGLAS RD S STE 150
-----------------------------------------------------
City | COTTAGE GROVE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55016-3045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-340-4000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7145 E POINT DOUGLAS RD S STE 150
-----------------------------------------------------
City | COTTAGE GROVE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55016-3045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-340-4000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PATRICK FLYNN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 920-660-7877
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------