Provider Demographics
NPI:1073767372
Name:HEALTHSOURCE OF WHITE BEAR LAKE, PLLC
Entity Type:Organization
Organization Name:HEALTHSOURCE OF WHITE BEAR LAKE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LEO
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-762-5433
Mailing Address - Street 1:4801 HIGHWAY 61 N
Mailing Address - Street 2:105
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-2737
Mailing Address - Country:US
Mailing Address - Phone:651-762-5433
Mailing Address - Fax:651-762-7504
Practice Address - Street 1:4801 HIGHWAY 61 N
Practice Address - Street 2:105
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-2737
Practice Address - Country:US
Practice Address - Phone:651-762-5433
Practice Address - Fax:651-762-7504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-13
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5114111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty