Provider Demographics
NPI:1609068048
Name:PRIOR LAKE NATURAL HEALTH CLINIC
Entity Type:Organization
Organization Name:PRIOR LAKE NATURAL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:DR
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:TREMMEL
Authorized Official - Last Name:NYHUS
Authorized Official - Suffix:
Authorized Official - Credentials:DC, DICCP
Authorized Official - Phone:952-226-1140
Mailing Address - Street 1:16228 MAIN AVE SE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-1770
Mailing Address - Country:US
Mailing Address - Phone:952-226-1140
Mailing Address - Fax:952-226-1141
Practice Address - Street 1:16228 MAIN AVE SE
Practice Address - Street 2:SUITE 105
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-1770
Practice Address - Country:US
Practice Address - Phone:952-226-1140
Practice Address - Fax:952-226-1141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDC3878111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty