Provider Demographics
NPI:1639456197
Name:GRAND RAPIDS CHIROPRACTIC, PLLC
Entity Type:Organization
Organization Name:GRAND RAPIDS CHIROPRACTIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:MAY
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-234-0337
Mailing Address - Street 1:PO BOX 327
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-0327
Mailing Address - Country:US
Mailing Address - Phone:218-326-1030
Mailing Address - Fax:218-326-6927
Practice Address - Street 1:1415 E US HIGHWAY 169
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3375
Practice Address - Country:US
Practice Address - Phone:218-326-1030
Practice Address - Fax:218-326-6927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-11
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5078111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty