Provider Demographics
NPI:1609265156
Name:VIBRANT CHIROPRACTIC P.A.
Entity Type:Organization
Organization Name:VIBRANT CHIROPRACTIC P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THAD
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:BETZOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-207-4411
Mailing Address - Street 1:8519 EAGLE POINT BLVD STE 175
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-8629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8519 EAGLE POINT BLVD STE 175
Practice Address - Street 2:
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-8629
Practice Address - Country:US
Practice Address - Phone:651-207-4411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6027111N00000X
MN6028111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty