Provider Demographics
NPI:1710251384
Name:ELLINGSON CHIROPRACTIC CLINIC, PC
Entity Type:Organization
Organization Name:ELLINGSON CHIROPRACTIC CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:ELLINGSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:320-251-3828
Mailing Address - Street 1:140 3RD ST N
Mailing Address - Street 2:
Mailing Address - City:WAITE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:56387-1206
Mailing Address - Country:US
Mailing Address - Phone:320-251-3828
Mailing Address - Fax:320-258-4481
Practice Address - Street 1:140 3RD ST N
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-1206
Practice Address - Country:US
Practice Address - Phone:320-251-3828
Practice Address - Fax:320-258-4481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-29
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2703261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN359000234Medicare UPIN