Provider Demographics
NPI:1639349269
Name:FINISH LINE CHIROPRACTIC P.A.
Entity Type:Organization
Organization Name:FINISH LINE CHIROPRACTIC P.A.
Other - Org Name:FINISH LINE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:MIDBOE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-209-1429
Mailing Address - Street 1:4401 EGAN DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-2024
Mailing Address - Country:US
Mailing Address - Phone:952-746-4162
Mailing Address - Fax:952-808-3112
Practice Address - Street 1:4401 EGAN DR STE 100
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378
Practice Address - Country:US
Practice Address - Phone:952-746-4162
Practice Address - Fax:952-808-3112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5677111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN37M47FIOtherBCBS ID NUMBER
MN146690100Medicaid
MN37M47FIOtherBCBS ID NUMBER