Provider Demographics
NPI:1497052898
Name:FISHTRAP LAKE ENTERPRISES INC.
Entity Type:Organization
Organization Name:FISHTRAP LAKE ENTERPRISES INC.
Other - Org Name:HIDDEN VALLEY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:NOVAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-895-1120
Mailing Address - Street 1:3701 HIGHWAY 13 W
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-1721
Mailing Address - Country:US
Mailing Address - Phone:952-895-1120
Mailing Address - Fax:952-895-5377
Practice Address - Street 1:3701 HIGHWAY 13 W
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-1721
Practice Address - Country:US
Practice Address - Phone:952-895-1120
Practice Address - Fax:952-895-5377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-21
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
35000218Medicare UPIN