Provider Demographics
NPI:1679615090
Name:GODFREY CHIROPRACTIC CLINIC INC
Entity Type:Organization
Organization Name:GODFREY CHIROPRACTIC CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:
Authorized Official - Last Name:BAYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-762-8185
Mailing Address - Street 1:119 6TH AVE E
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-1801
Mailing Address - Country:US
Mailing Address - Phone:320-762-8185
Mailing Address - Fax:320-762-8186
Practice Address - Street 1:119 6TH AVE E
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-1801
Practice Address - Country:US
Practice Address - Phone:320-762-8185
Practice Address - Fax:320-762-8186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1436111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN499325000Medicaid
MN350003230Medicare UPIN