Provider Demographics
NPI:1689910291
Name:CORCORAN FAMILY CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:CORCORAN FAMILY CHIROPRACTIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLLE
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:DIEDRICH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-239-9880
Mailing Address - Street 1:89 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:ZUMBROTA
Mailing Address - State:MN
Mailing Address - Zip Code:55992
Mailing Address - Country:US
Mailing Address - Phone:952-239-9880
Mailing Address - Fax:
Practice Address - Street 1:89 W 9TH ST
Practice Address - Street 2:
Practice Address - City:ZUMBROTA
Practice Address - State:MN
Practice Address - Zip Code:55992-1255
Practice Address - Country:US
Practice Address - Phone:952-239-9880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-31
Last Update Date:2023-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4779111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty