Provider Demographics
NPI:1629388533
Name:NORTHSTAR CHIROPRACTIC & WELLNESS, P. A.
Entity Type:Organization
Organization Name:NORTHSTAR CHIROPRACTIC & WELLNESS, P. A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:ERIK
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:D C
Authorized Official - Phone:763-263-8433
Mailing Address - Street 1:670 HUMBOLDT DR
Mailing Address - Street 2:PO BOX 88
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-9407
Mailing Address - Country:US
Mailing Address - Phone:763-263-8433
Mailing Address - Fax:763-263-2963
Practice Address - Street 1:670 HUMBOLDT DR
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309-9407
Practice Address - Country:US
Practice Address - Phone:763-263-8433
Practice Address - Fax:763-263-2963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3099111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN300463500Medicaid
MN350002193Medicare PIN
MNU53862Medicare UPIN