Provider Demographics
NPI:1285178301
Name:LEGACY CHIROPRACTIC AND WELLNESS PLLC
Entity type:Organization
Organization Name:LEGACY CHIROPRACTIC AND WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRODERICK
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:SCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-236-1187
Mailing Address - Street 1:1675 CENTER AVE W
Mailing Address - Street 2:SUITE B
Mailing Address - City:DILWORTH
Mailing Address - State:MN
Mailing Address - Zip Code:56529-1346
Mailing Address - Country:US
Mailing Address - Phone:218-236-1187
Mailing Address - Fax:218-236-8514
Practice Address - Street 1:1675 CENTER AVE W
Practice Address - Street 2:SUITE B
Practice Address - City:DILWORTH
Practice Address - State:MN
Practice Address - Zip Code:56529-1346
Practice Address - Country:US
Practice Address - Phone:218-236-1187
Practice Address - Fax:218-236-8514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6294111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty