Provider Demographics
NPI:1821182734
Name:NORTHERN LIFE CHIROPRACTIC, P.A.
Entity Type:Organization
Organization Name:NORTHERN LIFE CHIROPRACTIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:FAWN
Authorized Official - Last Name:SHAFIEI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-890-0804
Mailing Address - Street 1:13955 W PRESERVE BLVD # 200
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-7733
Mailing Address - Country:US
Mailing Address - Phone:952-890-0804
Mailing Address - Fax:952-890-1095
Practice Address - Street 1:13955 W PRESERVE BLVD # 200
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-7733
Practice Address - Country:US
Practice Address - Phone:952-890-0804
Practice Address - Fax:952-890-1095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN38B71NOOtherBCBS ID NUMBER
MN302103300Medicaid
C02834Medicare PIN