Provider Demographics
NPI:1538468293
Name:INTEGRATED CHIROPRACTIC SERVICES
Entity Type:Organization
Organization Name:INTEGRATED CHIROPRACTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:VENABLES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-287-8780
Mailing Address - Street 1:4422 WHITE BEAR AVE N
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3475
Mailing Address - Country:US
Mailing Address - Phone:651-287-8780
Mailing Address - Fax:651-287-8786
Practice Address - Street 1:4422 WHITE BEAR AVE N
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3475
Practice Address - Country:US
Practice Address - Phone:651-287-8780
Practice Address - Fax:651-287-8786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-21
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3592111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN822520600Medicaid
MN350002649Medicare PIN
MNH81071Medicare UPIN