1265702690 NPI number — HEALTH QUEST FAMILY CHIROPRACTIC, LLC

Table of content: (NPI 1265702690)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265702690 NPI number — HEALTH QUEST FAMILY CHIROPRACTIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTH QUEST FAMILY CHIROPRACTIC, 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:
1265702690
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
213 LABREE AVE N
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
THIEF RIVER FALLS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56701-2022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-212-3294
Provider Business Mailing Address Fax Number:
855-245-5546

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
213 LABREE AVE N
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
THIEF RIVER FALLS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56701-2022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-212-3294
Provider Business Practice Location Address Fax Number:
855-245-5546
Provider Enumeration Date:
01/02/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WISETH
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CHIROPRACTOR/OWNER
Authorized Official Telephone Number:
701-212-3294

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  5506 , 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: 1407148554 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".