Provider Demographics
NPI:1821482126
Name:AVID HEALTH AND WELLNESS CHIROPRACTIC
Entity Type:Organization
Organization Name:AVID HEALTH AND WELLNESS CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TARA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-215-9411
Mailing Address - Street 1:572 HARRINGTON RD
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-1550
Mailing Address - Country:US
Mailing Address - Phone:952-215-9411
Mailing Address - Fax:
Practice Address - Street 1:700 TWELVE OAKS CENTER DR
Practice Address - Street 2:SUITE 734
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-4401
Practice Address - Country:US
Practice Address - Phone:952-215-9411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-24
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6055111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty