Provider Demographics
NPI:1437340205
Name:PRAIRIE VILLAGE CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:PRAIRIE VILLAGE CHIROPRACTIC CLINIC
Other - Org Name:CHIROCENTER-EDEN PRAIRIE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:BECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-937-1226
Mailing Address - Street 1:7810 TERREY PINE CT
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347-1186
Mailing Address - Country:US
Mailing Address - Phone:952-937-1226
Mailing Address - Fax:952-906-1811
Practice Address - Street 1:7810 TERREY PINE CT
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55347-1186
Practice Address - Country:US
Practice Address - Phone:952-937-1226
Practice Address - Fax:952-906-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN1230111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNT39474Medicare UPIN