Provider Demographics
NPI:1285812412
Name:SDS GROUP PA
Entity type:Organization
Organization Name:SDS GROUP PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SALITA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:612-991-3139
Mailing Address - Street 1:3813 PLYMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-5001
Mailing Address - Country:US
Mailing Address - Phone:612-991-3139
Mailing Address - Fax:
Practice Address - Street 1:4833 MINNETONKA BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2214
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SDS GROUP PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-11
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4370111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN787250000Medicaid
MN1065328OtherBCBS CLINIC ID
MN119H8CHOtherBCBS MN ID#