Provider Demographics
NPI:1427248020
Name:RIVERVIEW CHIROPRACTIC CLINIC PA
Entity type:Organization
Organization Name:RIVERVIEW CHIROPRACTIC CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMISON
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:ENGLUND
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-236-1516
Mailing Address - Street 1:3505 8TH ST S STE 6
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-5108
Mailing Address - Country:US
Mailing Address - Phone:218-236-1516
Mailing Address - Fax:218-331-0077
Practice Address - Street 1:3505 8TH ST S STE 6
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-5108
Practice Address - Country:US
Practice Address - Phone:218-236-1516
Practice Address - Fax:218-331-0077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3979111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN622620500Medicaid
MN622620500Medicaid
MN350003611Medicare PIN