Provider Demographics
NPI:1457556730
Name:ST. PAUL NECK & BACK CLINIC, PC
Entity type:Organization
Organization Name:ST. PAUL NECK & BACK CLINIC, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:STADTHER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-560-9139
Mailing Address - Street 1:2781 FREEWAY BLVD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-1753
Mailing Address - Country:US
Mailing Address - Phone:763-560-9139
Mailing Address - Fax:763-560-9149
Practice Address - Street 1:2781 FREEWAY BLVD
Practice Address - Street 2:SUITE 160
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-1753
Practice Address - Country:US
Practice Address - Phone:763-560-9139
Practice Address - Fax:763-560-9149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3945111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty