Provider Demographics
NPI:1174560064
Name:WEDGEWOOD CHIROPRACTIC, P.A.
Entity type:Organization
Organization Name:WEDGEWOOD CHIROPRACTIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CHIEF EXECUTIVE OFFIC
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-731-5124
Mailing Address - Street 1:3060 WOODBURY DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-9617
Mailing Address - Country:US
Mailing Address - Phone:651-731-5124
Mailing Address - Fax:651-731-0509
Practice Address - Street 1:3060 WOODBURY DR
Practice Address - Street 2:SUITE A
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55129-9617
Practice Address - Country:US
Practice Address - Phone:651-731-5124
Practice Address - Fax:651-731-0509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN03N70WEOtherBCBS