Provider Demographics
NPI:1588711857
Name:CAPITOL CHIROPRACTIC & REHAB., PC
Entity type:Organization
Organization Name:CAPITOL CHIROPRACTIC & REHAB., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:DAVISON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:651-771-2012
Mailing Address - Street 1:1408 ARCADE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-1823
Mailing Address - Country:US
Mailing Address - Phone:651-771-2012
Mailing Address - Fax:651-771-8747
Practice Address - Street 1:1408 ARCADE ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-1823
Practice Address - Country:US
Practice Address - Phone:651-771-2012
Practice Address - Fax:651-771-8747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3462111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNY25713Medicare UPIN