Provider Demographics
NPI:1518414382
Name:612 CHIROPRACTIC & WELLNESS
Entity Type:Organization
Organization Name:612 CHIROPRACTIC & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUMBARD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:612-578-6001
Mailing Address - Street 1:2211 MONROE ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-3635
Mailing Address - Country:US
Mailing Address - Phone:612-578-6001
Mailing Address - Fax:
Practice Address - Street 1:750 MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:MENDOTA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55118-3764
Practice Address - Country:US
Practice Address - Phone:612-578-6001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6232111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty