Provider Demographics
NPI:1487721684
Name:LIGHTHOUSE CHIROPRACTIC HEALTH CENTER, INC
Entity type:Organization
Organization Name:LIGHTHOUSE CHIROPRACTIC HEALTH CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:O
Authorized Official - Last Name:ENG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-441-1701
Mailing Address - Street 1:710 DODGE AVE NW
Mailing Address - Street 2:SUITE C
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-2019
Mailing Address - Country:US
Mailing Address - Phone:763-441-1701
Mailing Address - Fax:763-441-5348
Practice Address - Street 1:710 DODGE AVE NW
Practice Address - Street 2:SUITE C
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-2019
Practice Address - Country:US
Practice Address - Phone:763-441-1701
Practice Address - Fax:763-441-5348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3331111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5C580STOtherBLUE CROSS BLUE SHIELD
MN6855253-00Medicaid
MN6855253-00Medicaid
MN350001567Medicare ID - Type Unspecified