Provider Demographics
NPI:1659563310
Name:BOSSART CHIROPRACTIC LIFE CENTER PC
Entity Type:Organization
Organization Name:BOSSART CHIROPRACTIC LIFE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BOSSART
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-239-4710
Mailing Address - Street 1:1815 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4900
Mailing Address - Country:US
Mailing Address - Phone:701-239-4710
Mailing Address - Fax:701-239-4719
Practice Address - Street 1:1815 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4900
Practice Address - Country:US
Practice Address - Phone:701-239-4710
Practice Address - Fax:701-239-4719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND549111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3C874BOOtherBLUE CROSS BLUE SHIELD MN
ND01189001OtherBLUE CROSS BLUE SHIELD ND
ND18215Medicaid
ND549OtherCOMMERCIAL
ND549OtherCOMMERCIAL
NDU48792Medicare UPIN