Provider Demographics
NPI:1336512920
Name:WELLSPRING SPINAL CARE, PC
Entity Type:Organization
Organization Name:WELLSPRING SPINAL CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:ORTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-303-9124
Mailing Address - Street 1:12209 DAVENPORT ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4740
Mailing Address - Country:US
Mailing Address - Phone:952-303-9124
Mailing Address - Fax:
Practice Address - Street 1:540 GREENHAVEN RD
Practice Address - Street 2:SUITE 204
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-1674
Practice Address - Country:US
Practice Address - Phone:952-303-9124
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5746111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty