Provider Demographics
NPI:1316244882
Name:EXODUS CHIROPRACTIC, PA
Entity type:Organization
Organization Name:EXODUS CHIROPRACTIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:STYBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-786-5585
Mailing Address - Street 1:10950 CLUB WEST PKWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4679
Mailing Address - Country:US
Mailing Address - Phone:763-786-5585
Mailing Address - Fax:763-786-1003
Practice Address - Street 1:10950 CLUB WEST PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-4679
Practice Address - Country:US
Practice Address - Phone:763-786-5585
Practice Address - Fax:763-786-1003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-18
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4899111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty