Provider Demographics
NPI:1760966147
Name:ST BONIFACIUS CHIROPRACTIC L.L.C.
Entity Type:Organization
Organization Name:ST BONIFACIUS CHIROPRACTIC L.L.C.
Other - Org Name:ST. BONIFACIUS CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHASE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-202-5963
Mailing Address - Street 1:PO BOX 268
Mailing Address - Street 2:
Mailing Address - City:ST BONIFACIUS
Mailing Address - State:MN
Mailing Address - Zip Code:55375-0268
Mailing Address - Country:US
Mailing Address - Phone:952-446-1800
Mailing Address - Fax:952-446-1801
Practice Address - Street 1:4080 TOWER ST STE 1080
Practice Address - Street 2:
Practice Address - City:ST BONIFACIUS
Practice Address - State:MN
Practice Address - Zip Code:55375-1144
Practice Address - Country:US
Practice Address - Phone:952-446-1800
Practice Address - Fax:952-446-1801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-20
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty