MEDICARE: NORTHWEST CHIROPRACTIC P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	4512	MN

General Provider Information

NPI Number	:	1336157973
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWEST CHIROPRACTIC P.A.

Provider Business Mailing Address
First Line	:	2703 E LAKE ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-1927
Country	:	US
Telephone Number	:	612-442-2437
Fax Number	:	612-367-4029

Provider Business Practice Location Address
First Line	:	2703 E LAKE ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-1927
Country	:	US
Telephone Number	:	612-442-2437
Fax Number	:	612-367-4029

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DARRYL M HUMENNY
Credential	:	D.C.
Telephone Number	:	612-442-2437

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	02/18/2016

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