Provider Demographics
NPI:1548324023
Name:ELITE CHIROPRACTIC BROOKINGS PROF
Entity type:Organization
Organization Name:ELITE CHIROPRACTIC BROOKINGS PROF
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT,OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:WILDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:612-910-6600
Mailing Address - Street 1:20456 LAKE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-7805
Mailing Address - Country:US
Mailing Address - Phone:952-492-5914
Mailing Address - Fax:952-492-5913
Practice Address - Street 1:1453 6TH ST
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-1604
Practice Address - Country:US
Practice Address - Phone:605-692-2225
Practice Address - Fax:605-697-5838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1095111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty