Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 383670534 | MN |
N | 111NS0005X | Chiropractic Sports Physician | 383670534 | MN |
NPI | 1184928665 |
---|---|
Provider Name | Dr. Renata R Evertz |
First Address | Blaine, MN 55434 |
Second Address | Maple Grove, MN 55369 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/12/2010 |
Last Update Date | 27/01/2011 |