Provider Demographics
NPI:1083688345
Name:FAMILY CHIROPRACTIC CENTER, PA
Entity type:Organization
Organization Name:FAMILY CHIROPRACTIC CENTER, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MICKELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-460-9449
Mailing Address - Street 1:20700 CHIPPENDALE AVE W STE 7
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024-8206
Mailing Address - Country:US
Mailing Address - Phone:651-460-9449
Mailing Address - Fax:651-279-2148
Practice Address - Street 1:20700 CHIPPENDALE AVE W STE 7
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55024-8206
Practice Address - Country:US
Practice Address - Phone:651-460-9449
Practice Address - Fax:651-279-2148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-14
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1020261Q00000X
261Q00000X
MN4381261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN56688TRMedicare UPIN
MN350610726Medicare ID - Type Unspecified