Basic Information
| Provider Information | |||||||||
| NPI: | 1740485911 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FULDA FAMILY CHIROPRACTIC, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 108 N ST PAUL AVE | ||||||||
| Address2: | |||||||||
| City: | FULDA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 561314463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5074250025 | ||||||||
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| Practice Location | |||||||||
| Address1: | 108 N ST PAUL AVE | ||||||||
| Address2: | |||||||||
| City: | FULDA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 561314463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5074250025 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 01/22/2015 | ||||||||
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| AuthorizedOfficialLastName: | GRABER | ||||||||
| AuthorizedOfficialFirstName: | TONY | ||||||||
| AuthorizedOfficialMiddleName: | JONATHAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5074250025 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.C. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 4970 | MN | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
No ID Information.