Provider Demographics
NPI:1053490615
Name:ADVANCED BACK TECHNOLOGY, P.A.
Entity Type:Organization
Organization Name:ADVANCED BACK TECHNOLOGY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:CLAUSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-473-1663
Mailing Address - Street 1:1421 WAYZATA BLVD EAST
Mailing Address - Street 2:SUITE 70
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391
Mailing Address - Country:US
Mailing Address - Phone:952-473-1663
Mailing Address - Fax:952-473-9662
Practice Address - Street 1:1421 WAYZATA BLVD EAST
Practice Address - Street 2:SUITE 70
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391
Practice Address - Country:US
Practice Address - Phone:952-473-1663
Practice Address - Fax:952-473-9662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1911111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN097K2ADOtherBLUE CROSS ID NUMBER