Provider Demographics
NPI:1821116682
Name:NORTHLAND CHIROPRACTIC CENTER PA
Entity Type:Organization
Organization Name:NORTHLAND CHIROPRACTIC CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ELYSE
Authorized Official - Last Name:PEDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-844-5050
Mailing Address - Street 1:516 MAIN STREET EAST
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501
Mailing Address - Country:US
Mailing Address - Phone:218-844-5050
Mailing Address - Fax:218-844-5049
Practice Address - Street 1:516 MAIN STREET EAST
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501
Practice Address - Country:US
Practice Address - Phone:218-844-5050
Practice Address - Fax:218-844-5049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
242T6N0OtherBCBS OF MN
647163OtherCHIROCARE OF MN
MN020960100Medicaid
647163OtherCHIROCARE OF MN
MN020960100Medicaid