Provider Demographics
NPI:1528258068
Name:PURE CHIROPRACTIC, PA
Entity type:Organization
Organization Name:PURE CHIROPRACTIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERICK
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-740-4321
Mailing Address - Street 1:404 W SUPERIOR ST
Mailing Address - Street 2:STE 225 C
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1559
Mailing Address - Country:US
Mailing Address - Phone:218-740-4321
Mailing Address - Fax:218-740-4322
Practice Address - Street 1:404 W SUPERIOR ST
Practice Address - Street 2:SUITE 225 C
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1559
Practice Address - Country:US
Practice Address - Phone:218-740-4321
Practice Address - Fax:218-740-4322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3803111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN68492900Medicaid
MNU82302Medicare UPIN