Provider Demographics
NPI:1578700225
Name:DULUTH NATURAL MEDICINE & CHIROPRACTIC, PA
Entity Type:Organization
Organization Name:DULUTH NATURAL MEDICINE & CHIROPRACTIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES/ CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBB
Authorized Official - Middle Name:EVAN
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-724-4525
Mailing Address - Street 1:1731 LONDON RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55812-3846
Mailing Address - Country:US
Mailing Address - Phone:218-724-4525
Mailing Address - Fax:218-728-0089
Practice Address - Street 1:1731 LONDON RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55812-3846
Practice Address - Country:US
Practice Address - Phone:218-724-4525
Practice Address - Fax:218-728-0089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-17
Last Update Date:2009-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1808MN111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN164027500Medicaid
3K012ANOtherBCBSMN
MN164027500Medicaid
MN350002266Medicare PIN