Provider Demographics
NPI:1497774640
Name:FAMILY TREE CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:FAMILY TREE CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALYSSA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SATERDALEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-697-4044
Mailing Address - Street 1:1660 HIGHWAY 100 S STE 500
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1551
Mailing Address - Country:US
Mailing Address - Phone:952-697-4044
Mailing Address - Fax:
Practice Address - Street 1:6311 WAYZATA BLVD STE 330
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1288
Practice Address - Country:US
Practice Address - Phone:952-930-0699
Practice Address - Fax:952-933-6410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4546111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN530008000Medicaid
MN11N61FAOtherBC/BS OF MINNESOTA
665914OtherACN PROVIDER
665914OtherACN PROVIDER
350003681Medicare PIN