Provider Demographics
NPI:1760660427
Name:GREEN LAKE CHIROPRACTIC, PA
Entity Type:Organization
Organization Name:GREEN LAKE CHIROPRACTIC, PA
Other - Org Name:MERIDIAN DISC INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:D
Authorized Official - Last Name:HAEFNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:320-214-0044
Mailing Address - Street 1:205 5TH ST SW
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-3211
Mailing Address - Country:US
Mailing Address - Phone:320-214-0044
Mailing Address - Fax:320-214-0045
Practice Address - Street 1:205 5TH ST SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3211
Practice Address - Country:US
Practice Address - Phone:320-214-0044
Practice Address - Fax:320-214-0045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4176261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN627686OtherACN GROUP
MN0868OtherHEALTH SERVICE MGMT.
MN062M1GROtherMN BCBS
MNC04837Medicare PIN