Provider Demographics
NPI:1669486015
Name:PARK CHIROPRACTIC CLINIC, INC.
Entity Type:Organization
Organization Name:PARK CHIROPRACTIC CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:320-252-8383
Mailing Address - Street 1:4 13TH AVE N
Mailing Address - Street 2:
Mailing Address - City:WAITE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:56387-1036
Mailing Address - Country:US
Mailing Address - Phone:320-252-8383
Mailing Address - Fax:320-252-9028
Practice Address - Street 1:4 13TH AVE N
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-1036
Practice Address - Country:US
Practice Address - Phone:320-252-8383
Practice Address - Fax:320-252-9028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN364261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN155216300Medicaid
MN6C337PAOtherBCBS
350001679Medicare ID - Type UnspecifiedREGULAR MEDICARE
MN155216300Medicaid
350041524Medicare ID - Type UnspecifiedRAILROAD MEDICARE