Provider Demographics
NPI:1578621710
Name:LIFELINE CHIROPRACTIC , P.A.
Entity Type:Organization
Organization Name:LIFELINE CHIROPRACTIC , P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:DURICK
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-735-9353
Mailing Address - Street 1:2165 WOODLANE DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2915
Mailing Address - Country:US
Mailing Address - Phone:651-735-9353
Mailing Address - Fax:651-735-8282
Practice Address - Street 1:2165 WOODLANE DR
Practice Address - Street 2:SUITE 102
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2915
Practice Address - Country:US
Practice Address - Phone:651-735-9353
Practice Address - Fax:651-735-8282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3994111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN996448700Medicaid
MN007J2LIOtherBCBSMN
MN007J2LIOtherBCBSMN
MN350002410Medicare ID - Type UnspecifiedMEDICARE