Provider Demographics
NPI:1417045378
Name:VISTAD CHIROPRACTIC CLINIC PA
Entity Type:Organization
Organization Name:VISTAD CHIROPRACTIC CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:VISTAD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-736-5676
Mailing Address - Street 1:301 NORTH UNION
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537
Mailing Address - Country:US
Mailing Address - Phone:218-736-5676
Mailing Address - Fax:218-736-5677
Practice Address - Street 1:301 NORTH UNION
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537
Practice Address - Country:US
Practice Address - Phone:218-736-5676
Practice Address - Fax:218-736-5677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN60667VIOtherBLUE CROSS
T82064Medicare UPIN