Provider Demographics
NPI:1467676346
Name:HEAVEN'S GATE CHIROPRACTIC, PC
Entity Type:Organization
Organization Name:HEAVEN'S GATE CHIROPRACTIC, PC
Other - Org Name:DR. KROLL'S HEALTH SOLUTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:KROLL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-388-4378
Mailing Address - Street 1:305 BUSH ST
Mailing Address - Street 2:
Mailing Address - City:RED WING
Mailing Address - State:MN
Mailing Address - Zip Code:55066-2527
Mailing Address - Country:US
Mailing Address - Phone:651-388-4378
Mailing Address - Fax:651-388-4385
Practice Address - Street 1:305 BUSH ST
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-2527
Practice Address - Country:US
Practice Address - Phone:651-388-4378
Practice Address - Fax:651-388-4385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN2593111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN382R1HEOtherBLUE CROSS BLUE SHIELD
MN843828500Medicaid
MN843828500Medicaid