Provider Demographics
NPI:1548653090
Name:EVENING CHIROPRACTIC CLINIC LLC
Entity type:Organization
Organization Name:EVENING CHIROPRACTIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:RENELUS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-419-1069
Mailing Address - Street 1:1626 VINCENT AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-2839
Mailing Address - Country:US
Mailing Address - Phone:651-419-1069
Mailing Address - Fax:
Practice Address - Street 1:1885 UNIVERSITY AVE W
Practice Address - Street 2:140
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3489
Practice Address - Country:US
Practice Address - Phone:651-419-1069
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4047971-2111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty