Provider Demographics
NPI:1609053396
Name:BRAATEN CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:BRAATEN CHIROPRACTIC LLC
Other - Org Name:IMAGINE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BRAATEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:320-240-6561
Mailing Address - Street 1:750 1ST. ST. STE 103
Mailing Address - Street 2:
Mailing Address - City:WAITE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:56387
Mailing Address - Country:US
Mailing Address - Phone:320-240-6561
Mailing Address - Fax:320-240-9331
Practice Address - Street 1:750 1ST. ST. S. STE 103
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387
Practice Address - Country:US
Practice Address - Phone:320-240-6561
Practice Address - Fax:320-240-9331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-25
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4986111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN36M20IMOtherBLUE CROSS BLUE SHIELD GROUP PROVIDER ID
MNC04865OtherMEDICARE GROUP PTAN