Provider Demographics
NPI:1790932390
Name:EAGLE TRACE WELLNESS CENTER, PA
Entity Type:Organization
Organization Name:EAGLE TRACE WELLNESS CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, SECRETARY, TREASURE
Authorized Official - Prefix:DR
Authorized Official - First Name:ELISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KENSINGER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-808-2922
Mailing Address - Street 1:12002 COUNTY ROAD 11
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-3016
Mailing Address - Country:US
Mailing Address - Phone:952-808-2922
Mailing Address - Fax:952-808-2910
Practice Address - Street 1:12002 COUNTY ROAD 11
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-3016
Practice Address - Country:US
Practice Address - Phone:952-808-2922
Practice Address - Fax:952-808-2910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5077111N00000X
MN5104111N00000X
MN832171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty