Provider Demographics
NPI:1518174218
Name:FOUR SEASONS FAMILY CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:FOUR SEASONS FAMILY CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DC
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:SHINDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-557-9032
Mailing Address - Street 1:4455 HWY 169 N
Mailing Address - Street 2:STE 200
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55442
Mailing Address - Country:US
Mailing Address - Phone:763-557-9032
Mailing Address - Fax:763-557-9838
Practice Address - Street 1:4455 HWY 169 N
Practice Address - Street 2:STE 200
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55442
Practice Address - Country:US
Practice Address - Phone:763-557-9032
Practice Address - Fax:763-557-9838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2411111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN350002447OtherMEDICARE
MN60627FOOtherBCBS
MN191028100Medicaid
MNT39447Medicare UPIN