1841492428 NPI number — CHIROPRACTIC ADVANTAGE, LLC

Table of content: (NPI 1841492428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841492428 NPI number — CHIROPRACTIC ADVANTAGE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHIROPRACTIC ADVANTAGE, 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:
1841492428
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8900 PENN AVE S
Provider Second Line Business Mailing Address:
116
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55431-2068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-884-3700
Provider Business Mailing Address Fax Number:
612-656-0550

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8900 PENN AVE S
Provider Second Line Business Practice Location Address:
SUITE 116
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55431-2068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-884-3700
Provider Business Practice Location Address Fax Number:
612-656-0550
Provider Enumeration Date:
06/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ELIJAH
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER PRESIDENT
Authorized Official Telephone Number:
952-884-3700

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3278 , 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: 4485431 . This is a "MEDICA PROVIDER ID" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1B00B6CH . This is a "BCBS CLINIC ID" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 00B97EL . This is a "BCBS PROVIDER ID" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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