Provider Demographics
NPI:1972529634
Name:ELITE CHIROPRACTIC-NORTH ST. PAUL
Entity type:Organization
Organization Name:ELITE CHIROPRACTIC-NORTH ST. PAUL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT OF LLC
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:952-492-5914
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 1:2597 7TH AVE E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109-3104
Practice Address - Country:US
Practice Address - Phone:651-777-1710
Practice Address - Fax:651-777-9108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty