=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942411822
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OXBORO FAMILY CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9864 LYNDALE AVE S
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55420-4731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-948-9225
-----------------------------------------------------
Fax | 952-888-6011
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9864 LYNDALE AVE S
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55420-4731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-948-9225
-----------------------------------------------------
Fax | 952-888-6011
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JASON EDWARD ZIMMERMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 952-948-9225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3666
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------