Provider Demographics
NPI:1386010916
Name:CHIROPORT
Entity Type:Organization
Organization Name:CHIROPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:JACKSON
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-900-3562
Mailing Address - Street 1:1440 ARCADE ST STE C
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-1830
Mailing Address - Country:US
Mailing Address - Phone:651-900-3562
Mailing Address - Fax:
Practice Address - Street 1:1440 ARCADE ST STE C
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-1830
Practice Address - Country:US
Practice Address - Phone:651-900-3562
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-18
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6112111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty