Provider Demographics
NPI:1477610194
Name:NORTHWOODS CHIROPRACTIC P. A.
Entity Type:Organization
Organization Name:NORTHWOODS CHIROPRACTIC P. A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANICIA
Authorized Official - Middle Name:GWEN
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-692-1616
Mailing Address - Street 1:13743 E SHORE RD
Mailing Address - Street 2:
Mailing Address - City:CROSSLAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56442-4033
Mailing Address - Country:US
Mailing Address - Phone:218-692-1616
Mailing Address - Fax:218-692-1626
Practice Address - Street 1:13743 E SHORE RD
Practice Address - Street 2:
Practice Address - City:CROSSLAKE
Practice Address - State:MN
Practice Address - Zip Code:56442-4033
Practice Address - Country:US
Practice Address - Phone:218-692-1616
Practice Address - Fax:218-692-1626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3138111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN68D24NOOtherBCBS OFFICE ID #
MN68D25PEOtherBCBS INDIVIDUAL ID #
MNU43462Medicare UPIN