1053500090 NPI number — ELITE CHIROPRACTIC CLINIC LLC

Table of content: (NPI 1053500090)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053500090 NPI number — ELITE CHIROPRACTIC CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELITE CHIROPRACTIC CLINIC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053500090
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6001 EGAN DR STE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAVAGE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55378-4910
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-447-1565
Provider Business Mailing Address Fax Number:
952-447-1566

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6001 EGAN DR STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAVAGE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55378-4910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-447-1565
Provider Business Practice Location Address Fax Number:
952-447-1566
Provider Enumeration Date:
10/16/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MCFARLAND
Authorized Official First Name:
CASANDRA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OFFICIAL
Authorized Official Telephone Number:
952-447-1565

Provider Taxonomy Codes

  • Taxonomy code: 111NX0800X , with the licence number:  4346 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 039064000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 414M3EL . This is a "BLUE CROSS BLUE SHIELD MN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 414M4MC . This is a "BLUE CROSS BLUE SHIELD MN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4111508205 . This is a "HSM" identifier . This identifiers is of the category "OTHER".