1184766842 NPI number — ANOKA-ANDOVER CHIROPRACTIC, PA

Table of content: (NPI 1184766842)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184766842 NPI number — ANOKA-ANDOVER CHIROPRACTIC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANOKA-ANDOVER CHIROPRACTIC, PA
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:
1184766842
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3722 7TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANOKA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55303-1465
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-427-7122
Provider Business Mailing Address Fax Number:
763-427-4042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3722 7TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANOKA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55303-1465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-427-7122
Provider Business Practice Location Address Fax Number:
763-427-4042
Provider Enumeration Date:
02/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BILLSTEIN
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
763-427-7122

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1983 , 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: 510221000 . This is a "MN MEDICAL ASS. GROUP" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 20735BI . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 625327000 . This is a "MN MEDICAL ASS. INDIVDUAL" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 3710867 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: OG117BI . This is a "GROUP BLUE CROSS BLUE SHI" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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