Provider Demographics
NPI:1093864050
Name:CHIROPRACTIC REHABILITATION CENTER LLC
Entity Type:Organization
Organization Name:CHIROPRACTIC REHABILITATION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:JEROD
Authorized Official - Last Name:CRANE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-734-1123
Mailing Address - Street 1:9900 VALLEY CREEK RD #145
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125
Mailing Address - Country:US
Mailing Address - Phone:651-734-1123
Mailing Address - Fax:651-734-1109
Practice Address - Street 1:9900 VALLEY CREEK RD #145
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125
Practice Address - Country:US
Practice Address - Phone:651-734-1123
Practice Address - Fax:651-734-1109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3831111N00000X
MN4269111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN97D66CHOtherBLUE CROSS BLUE SHIELD