Provider Demographics
NPI:1114465366
Name:BLACKDUCK CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:BLACKDUCK CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:TJEPKES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-835-8837
Mailing Address - Street 1:22388 BLACKDUCK LAKE RD NE
Mailing Address - Street 2:
Mailing Address - City:BLACKDUCK
Mailing Address - State:MN
Mailing Address - Zip Code:56630-4226
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22388 BLACKDUCK LAKE RD NE
Practice Address - Street 2:
Practice Address - City:BLACKDUCK
Practice Address - State:MN
Practice Address - Zip Code:56630-4226
Practice Address - Country:US
Practice Address - Phone:218-835-8837
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-08
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6315111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty