Provider Demographics
NPI:1255661914
Name:MINNESOTA PAIN RELIEF AND WELLNESS INSTITUTE PA
Entity Type:Organization
Organization Name:MINNESOTA PAIN RELIEF AND WELLNESS INSTITUTE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-288-3098
Mailing Address - Street 1:2151 HAMLINE AVE N
Mailing Address - Street 2:STE 111
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-4236
Mailing Address - Country:US
Mailing Address - Phone:651-288-3098
Mailing Address - Fax:651-288-3781
Practice Address - Street 1:2151 HAMLINE AVE N
Practice Address - Street 2:STE 111
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4236
Practice Address - Country:US
Practice Address - Phone:651-288-3098
Practice Address - Fax:763-210-6890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-31
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3525111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty