Basic Information
| Provider Information | |||||||||
| NPI: | 1952466542 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAULY | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BS DC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JENSEN | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | BS DC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1405 78TH ST STE 100 | ||||||||
| Address2: | PO BOX 93 | ||||||||
| City: | VICTORIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553869723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524433710 | ||||||||
| FaxNumber: | 9524433761 | ||||||||
| Practice Location | |||||||||
| Address1: | 1405 78TH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | VICTORIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553869723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524433710 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2006 | ||||||||
| LastUpdateDate: | 12/31/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 4549 | MN | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 378615300 | 05 | MN | MEDICAID |