Provider Demographics
NPI:1417260779
Name:WILLMAR CHIROPRACTIC CLINIC P.A.
Entity Type:Organization
Organization Name:WILLMAR CHIROPRACTIC CLINIC P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:LEIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:320-235-7347
Mailing Address - Street 1:1950 19TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-4925
Mailing Address - Country:US
Mailing Address - Phone:320-235-7347
Mailing Address - Fax:320-222-2826
Practice Address - Street 1:1950 19TH AVE SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-4925
Practice Address - Country:US
Practice Address - Phone:320-235-7347
Practice Address - Fax:320-222-2826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-15
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2839111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN725528400Medicaid
MN725528400Medicaid