=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760660427
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREEN LAKE CHIROPRACTIC, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2008
-----------------------------------------------------
Last Update Date | 06/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 5TH ST SW
-----------------------------------------------------
City | WILLMAR
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56201-3211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-214-0044
-----------------------------------------------------
Fax | 320-214-0045
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 205 5TH ST SW
-----------------------------------------------------
City | WILLMAR
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56201-3211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-214-0044
-----------------------------------------------------
Fax | 320-214-0045
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JON D. HAEFNER
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 320-214-0044
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | 4176
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------