Provider Demographics
NPI:1285829267
Name:CREST CHIROPRACTIC CLINIC
Entity type:Organization
Organization Name:CREST CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:C
Authorized Official - Last Name:RAWLINGS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-776-7100
Mailing Address - Street 1:1497 WHITE BEAR AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-2414
Mailing Address - Country:US
Mailing Address - Phone:651-776-7100
Mailing Address - Fax:651-776-2415
Practice Address - Street 1:1497 WHITE BEAR AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-2414
Practice Address - Country:US
Practice Address - Phone:651-776-7100
Practice Address - Fax:651-776-2415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1368111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty