Provider Demographics
NPI:1689733362
Name:MILLE LACS CHIROPRACTICS
Entity Type:Organization
Organization Name:MILLE LACS CHIROPRACTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:HASS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:320-983-2728
Mailing Address - Street 1:PO BOX 294
Mailing Address - Street 2:
Mailing Address - City:MILACA
Mailing Address - State:MN
Mailing Address - Zip Code:56353-0294
Mailing Address - Country:US
Mailing Address - Phone:320-983-2728
Mailing Address - Fax:320-983-2725
Practice Address - Street 1:1010 5TH ST SE
Practice Address - Street 2:
Practice Address - City:MILACA
Practice Address - State:MN
Practice Address - Zip Code:56353-1300
Practice Address - Country:US
Practice Address - Phone:320-983-2728
Practice Address - Fax:320-983-2725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2280111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN279727500Medicaid
MN3C131HAOtherBCBS
231223OtherCCMI
MN279727500Medicaid
MN3C131HAOtherBCBS