Provider Demographics
NPI:1487747226
Name:BASS LAKE CHIROPRACTIC CLINIC, P.A.
Entity type:Organization
Organization Name:BASS LAKE CHIROPRACTIC CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:VINJE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-537-8070
Mailing Address - Street 1:5640 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55428-3556
Mailing Address - Country:US
Mailing Address - Phone:763-537-8070
Mailing Address - Fax:763-537-9513
Practice Address - Street 1:5640 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55428-3556
Practice Address - Country:US
Practice Address - Phone:763-537-8070
Practice Address - Fax:763-537-9513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDC4020111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4C416HUOtherBCBS GROUP ID #
MNCO3234Medicare ID - Type UnspecifiedMEDICARE GROUP ID #