Provider Demographics
NPI:1992929541
Name:CITY LAKES CHIROPRACTIC PA
Entity type:Organization
Organization Name:CITY LAKES CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:612-722-2147
Mailing Address - Street 1:2903 E 42ND STREET
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406
Mailing Address - Country:US
Mailing Address - Phone:612-722-2147
Mailing Address - Fax:612-722-1581
Practice Address - Street 1:2903 E 42ND STREET
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406
Practice Address - Country:US
Practice Address - Phone:612-722-2147
Practice Address - Fax:612-722-1581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN508111N00000X
MN3363111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5374227-00Medicaid
MN43F05ANOtherBCBS
MN43F05ANOtherBCBS
MNU61116Medicare UPIN