Provider Demographics
NPI:1518287101
Name:SYVRUD CHIROPRACTIC CLINIC PC
Entity Type:Organization
Organization Name:SYVRUD CHIROPRACTIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:M
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-237-5150
Mailing Address - Street 1:825 25TH ST S STE C
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-8724
Mailing Address - Country:US
Mailing Address - Phone:701-237-5150
Mailing Address - Fax:701-237-5150
Practice Address - Street 1:825 25TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-8724
Practice Address - Country:US
Practice Address - Phone:701-237-5150
Practice Address - Fax:701-237-5150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-04
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND497111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND26293OtherBLUE CROSS BLUE SHIELD OF ND
340115OtherOPTUM HEALTH
ND16342Medicaid
MN63140SYOtherBLUE CROSS BLUE SHIELD OF MN
MN653528300Medicaid
350053619OtherRR MEDICARE
MN653528300Medicaid
ND16342Medicaid