Provider Demographics
NPI:1821499864
Name:HEADWATERS CHIROPRACTIC CENTER LLC
Entity Type:Organization
Organization Name:HEADWATERS CHIROPRACTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:JACQUES
Authorized Official - Last Name:LEVESQUE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-333-8811
Mailing Address - Street 1:1426 BEMIDJI AVE N
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601
Mailing Address - Country:US
Mailing Address - Phone:218-333-8811
Mailing Address - Fax:218-333-8813
Practice Address - Street 1:1426 BEMIDJI AVE N
Practice Address - Street 2:SUITE 2
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601
Practice Address - Country:US
Practice Address - Phone:218-333-8811
Practice Address - Fax:218-333-8813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-09
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty