Provider Demographics
NPI:1194809863
Name:CANNON VALLEY CHIROPRACTIC,LLC
Entity type:Organization
Organization Name:CANNON VALLEY CHIROPRACTIC,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:AUGUST
Authorized Official - Last Name:MAKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:507-263-3925
Mailing Address - Street 1:6505 CEDAR HILLS DR
Mailing Address - Street 2:
Mailing Address - City:CANNON FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:55009-4253
Mailing Address - Country:US
Mailing Address - Phone:507-263-3925
Mailing Address - Fax:507-263-5065
Practice Address - Street 1:6505 CEDAR HILLS DR
Practice Address - Street 2:
Practice Address - City:CANNON FALLS
Practice Address - State:MN
Practice Address - Zip Code:55009-4253
Practice Address - Country:US
Practice Address - Phone:507-263-3925
Practice Address - Fax:507-263-5065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4074111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01N79CAOtherBLUE CROSS/BLUE SHIELD
MNDD3466Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MN01N79CAOtherBLUE CROSS/BLUE SHIELD