1487721684 NPI number — LIGHTHOUSE CHIROPRACTIC HEALTH CENTER, INC

Table of content: (NPI 1487721684)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487721684 NPI number — LIGHTHOUSE CHIROPRACTIC HEALTH CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIGHTHOUSE CHIROPRACTIC HEALTH CENTER, INC
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:
1487721684
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
710 DODGE AVE NW
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
ELK RIVER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55330-2019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-441-1701
Provider Business Mailing Address Fax Number:
763-441-5348

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
710 DODGE AVE NW
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
ELK RIVER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55330-2019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-441-1701
Provider Business Practice Location Address Fax Number:
763-441-5348
Provider Enumeration Date:
11/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ENG
Authorized Official First Name:
MARTIN
Authorized Official Middle Name:
O
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
763-441-1701

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3331 , 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: 5C580ST . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6855253-00 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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