Provider Demographics
NPI:1003075615
Name:BOLINE FENSTRA CHIROPRACTIC PC
Entity Type:Organization
Organization Name:BOLINE FENSTRA CHIROPRACTIC PC
Other - Org Name:BOLINE FENSTRA CHIROPRACTIC PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENDALL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOLINE FENSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-235-0515
Mailing Address - Street 1:1101 1ST ST S
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-3592
Mailing Address - Country:US
Mailing Address - Phone:320-235-0515
Mailing Address - Fax:
Practice Address - Street 1:1101 1ST ST S
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3592
Practice Address - Country:US
Practice Address - Phone:320-235-0515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3122111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN900022400Medicaid
MN900022400Medicaid