1548324023 NPI number — ELITE CHIROPRACTIC BROOKINGS PROF

Table of content: (NPI 1548324023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548324023 NPI number — ELITE CHIROPRACTIC BROOKINGS PROF

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELITE CHIROPRACTIC BROOKINGS PROF
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:
COMPLETE CARE CHIROPRACTIC
Provider Other Organization Name Type Code:
3
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:
1548324023
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20456 LAKE RIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRIOR LAKE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55372-7805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-492-5914
Provider Business Mailing Address Fax Number:
952-492-5913

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1453 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKINGS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57006-1604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-692-2225
Provider Business Practice Location Address Fax Number:
605-697-5838
Provider Enumeration Date:
12/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILDBERG
Authorized Official First Name:
BRADLEY
Authorized Official Middle Name:
DALE
Authorized Official Title or Position:
PRESIDENT,OWNER
Authorized Official Telephone Number:
612-910-6600

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1095 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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