Provider Demographics
NPI:1306087630
Name:NEW YORK MILLS FAMILY SPINE CLINIC
Entity type:Organization
Organization Name:NEW YORK MILLS FAMILY SPINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:DAYLE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-385-3859
Mailing Address - Street 1:18 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:NEW YORK MILLS
Mailing Address - State:MN
Mailing Address - Zip Code:56567-0149
Mailing Address - Country:US
Mailing Address - Phone:218-385-3859
Mailing Address - Fax:218-385-3859
Practice Address - Street 1:18 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW YORK MILLS
Practice Address - State:MN
Practice Address - Zip Code:56567-0149
Practice Address - Country:US
Practice Address - Phone:218-385-3859
Practice Address - Fax:218-385-3859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-17
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDC 3903111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN350002087Medicare PIN