Provider Demographics
NPI:1689017097
Name:NORTHSIDE CHIROPRACTIC CLINIC LTD
Entity Type:Organization
Organization Name:NORTHSIDE CHIROPRACTIC CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:T
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:612-522-0440
Mailing Address - Street 1:3107 PENN AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-1123
Mailing Address - Country:US
Mailing Address - Phone:612-522-0440
Mailing Address - Fax:612-522-1816
Practice Address - Street 1:3107 PENN AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-1123
Practice Address - Country:US
Practice Address - Phone:612-522-0440
Practice Address - Fax:612-522-1816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-16
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2197111NI0013X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NI0013XChiropractic ProvidersChiropractorIndependent Medical ExaminerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN890828100Medicaid