1316989817 NPI number — CHIROPRACTIC SPORT & SPINAL REHAB PA

Table of content: (NPI 1316989817)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316989817 NPI number — CHIROPRACTIC SPORT & SPINAL REHAB PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHIROPRACTIC SPORT & SPINAL REHAB 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:
6
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:
1316989817
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 LAKE ST NW
Provider Second Line Business Mailing Address:
SUITE G, PO BOX 930
Provider Business Mailing Address City Name:
WARROAD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56763-2116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-386-1930
Provider Business Mailing Address Fax Number:
218-386-1921

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 LAKE ST NW
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
WARROAD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56763-2116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-386-1930
Provider Business Practice Location Address Fax Number:
218-386-1921
Provider Enumeration Date:
06/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ERICKSON
Authorized Official First Name:
LYLE
Authorized Official Middle Name:
RICHARD
Authorized Official Title or Position:
OWNER/CHIROPRACTOR
Authorized Official Telephone Number:
218-386-1930

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3705 , 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: 420M4CH . This is a "BCBS OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 485263000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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