Provider Demographics
NPI:1073915732
Name:PREMIER HEALTH OF COON RAPIDS, INC
Entity Type:Organization
Organization Name:PREMIER HEALTH OF COON RAPIDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHMIEL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-270-5828
Mailing Address - Street 1:3340 NORTHDALE BLVD NW
Mailing Address - Street 2:SUITE 120
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-1622
Mailing Address - Country:US
Mailing Address - Phone:763-270-5828
Mailing Address - Fax:763-270-5849
Practice Address - Street 1:3340 NORTHDALE BLVD NW
Practice Address - Street 2:SUITE 120
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-1622
Practice Address - Country:US
Practice Address - Phone:763-270-5828
Practice Address - Fax:763-270-5849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-24
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5855111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1386068658Medicaid
MN1386068658Medicaid