Provider Demographics
NPI:1740406685
Name:DIRECTCARE CHIROPRACTIC, PA
Entity Type:Organization
Organization Name:DIRECTCARE CHIROPRACTIC, PA
Other - Org Name:MINNESOTA SPINE & INJURY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:DEWALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-441-0644
Mailing Address - Street 1:804 FREEPORT AVE NW
Mailing Address - Street 2:STE. C
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-2632
Mailing Address - Country:US
Mailing Address - Phone:763-441-0644
Mailing Address - Fax:
Practice Address - Street 1:804 FREEPORT AVE NW
Practice Address - Street 2:STE. C
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-2632
Practice Address - Country:US
Practice Address - Phone:763-441-0644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4224111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN350003623Medicare ID - Type Unspecified
MNU90142Medicare UPIN