Provider Demographics
NPI:1366631244
Name:EAGLE CREEK WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:EAGLE CREEK WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-447-9935
Mailing Address - Street 1:14180 COMMERCE AVE NE
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-1483
Mailing Address - Country:US
Mailing Address - Phone:952-447-3395
Mailing Address - Fax:952-447-3396
Practice Address - Street 1:14180 COMMERCE AVE NE
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-1483
Practice Address - Country:US
Practice Address - Phone:952-447-3395
Practice Address - Fax:952-447-3396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDC3496111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN271223700Medicaid
MN747637000Medicaid
MN650001045Medicare PIN
MN747637000Medicaid