Provider Demographics
NPI:1376602656
Name:PEQUOT LAKES CHIROPRACTIC AND SPORTS INJURY CENTER P.A
Entity Type:Organization
Organization Name:PEQUOT LAKES CHIROPRACTIC AND SPORTS INJURY CENTER P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-DC
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BUELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-568-7767
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:
Mailing Address - City:PEQUOT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56472
Mailing Address - Country:US
Mailing Address - Phone:218-568-7767
Mailing Address - Fax:218-568-4580
Practice Address - Street 1:31095 BERGQUIST DRIVE
Practice Address - Street 2:
Practice Address - City:PEQUOT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56472-0008
Practice Address - Country:US
Practice Address - Phone:218-568-7767
Practice Address - Fax:218-568-4580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3271111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN043813800Medicaid
MN043813800Medicaid
MNU57821Medicare UPIN