Provider Demographics
NPI:1053329896
Name:CLEARWATER FAMILY CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:CLEARWATER FAMILY CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERON
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BORDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:320-558-6772
Mailing Address - Street 1:935 PROFESSIONAL BUILDING
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55320-0246
Mailing Address - Country:US
Mailing Address - Phone:320-558-6772
Mailing Address - Fax:320-558-4558
Practice Address - Street 1:935 PROFESSIONAL BUILDING
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:MN
Practice Address - Zip Code:55320-0246
Practice Address - Country:US
Practice Address - Phone:320-558-6772
Practice Address - Fax:320-558-4558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3952111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU84057Medicare UPIN