Provider Demographics
NPI:1164614202
Name:CROW RIVER ENTERPRISES
Entity Type:Organization
Organization Name:CROW RIVER ENTERPRISES
Other - Org Name:DBA CROW RIVER CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:JOHAN
Authorized Official - Last Name:JURGENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:320-587-2215
Mailing Address - Street 1:1507 JEFFERSON ST SE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HUTCHINSON
Mailing Address - State:MN
Mailing Address - Zip Code:55350
Mailing Address - Country:US
Mailing Address - Phone:320-587-2215
Mailing Address - Fax:
Practice Address - Street 1:1507 JEFFERSON ST SE
Practice Address - Street 2:SUITE 1
Practice Address - City:HUTCHINSON
Practice Address - State:MN
Practice Address - Zip Code:55350
Practice Address - Country:US
Practice Address - Phone:320-587-2215
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3383111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN603860OtherACN CHIROCARE
MN0303OtherPREFERRED ONE
MN344727800Medicaid
MN54F01CROtherBLUE CROSS BLUE SHIELD
MN54F01CROtherBLUE CROSS BLUE SHIELD
MN54F01CROtherBLUE CROSS BLUE SHIELD