MEDICARE: EAST BOUND AND DOWN REHAB PLLC

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	:	1770887424
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST BOUND AND DOWN REHAB PLLC

Provider Business Mailing Address
First Line	:	2703 E. LAKE ST.
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2703 E LAKE ST.
Second Line	:
City	:	MPLS
State	:	MN
Zip	:	55406
Country	:	US
Telephone Number	:	612-597-1371
Fax Number	:	763-545-8254

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DARRYL M HUMENNY
Credential	:	D.C.
Telephone Number	:	612-597-1371

Provider Enumeration Date	:	01/10/2011
Last Update Date	:	02/03/2011

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