Provider Demographics
NPI:1407144579
Name:SUMMIT WELLNESS CENTER
Entity Type:Organization
Organization Name:SUMMIT WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:OOMMEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-340-7511
Mailing Address - Street 1:6776 LAKE DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-1191
Mailing Address - Country:US
Mailing Address - Phone:651-340-7511
Mailing Address - Fax:651-340-7849
Practice Address - Street 1:6776 LAKE DR
Practice Address - Street 2:SUITE 210
Practice Address - City:LINO LAKES
Practice Address - State:MN
Practice Address - Zip Code:55014-1191
Practice Address - Country:US
Practice Address - Phone:651-340-7511
Practice Address - Fax:651-340-7849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-11
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5551111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty