Provider Demographics
NPI:1003941030
Name:SPRING LAKE PARK CHIROPRACTIC PA
Entity Type:Organization
Organization Name:SPRING LAKE PARK CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-784-1540
Mailing Address - Street 1:1611 COUNTY HIGHWAY 10
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55432-2124
Mailing Address - Country:US
Mailing Address - Phone:763-784-1540
Mailing Address - Fax:
Practice Address - Street 1:1611 COUNTY HIGHWAY 10
Practice Address - Street 2:
Practice Address - City:SPRING LAKE PARK
Practice Address - State:MN
Practice Address - Zip Code:55432-2124
Practice Address - Country:US
Practice Address - Phone:763-784-1540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3397111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty