Provider Demographics
NPI:1275553737
Name:LA CRESCENT CHIROPRACTIC, P.C.
Entity Type:Organization
Organization Name:LA CRESCENT CHIROPRACTIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:J
Authorized Official - Last Name:KIESAU
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:507-895-6015
Mailing Address - Street 1:306 MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LA CRESCENT
Mailing Address - State:MN
Mailing Address - Zip Code:55947-1828
Mailing Address - Country:US
Mailing Address - Phone:507-895-6015
Mailing Address - Fax:507-895-6345
Practice Address - Street 1:306 MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:LA CRESCENT
Practice Address - State:MN
Practice Address - Zip Code:55947-1828
Practice Address - Country:US
Practice Address - Phone:507-895-6015
Practice Address - Fax:507-895-6345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4226111N00000X
MN1575111N00000X
MN138171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Not Answered171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNT39703Medicare UPIN
MNU80408Medicare UPIN