Provider Demographics
NPI:1629355755
Name:CHIROCENTER MN, INC.
Entity Type:Organization
Organization Name:CHIROCENTER MN, INC.
Other - Org Name:UPTOWN CHIROCENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:ALLENBURG
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:763-537-3927
Mailing Address - Street 1:2073 W WAYZATA BLVD
Mailing Address - Street 2:
Mailing Address - City:LONG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55356-4517
Mailing Address - Country:US
Mailing Address - Phone:612-874-1313
Mailing Address - Fax:612-874-7575
Practice Address - Street 1:2112 LYNDALE AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-3026
Practice Address - Country:US
Practice Address - Phone:612-874-1313
Practice Address - Fax:612-874-7575
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LONG LAKE CHIROPRACTICE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-03
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC05824Medicare PIN