Provider Demographics
NPI:1851051742
Name:DEEP ROCK CHIROPRACTIC PC
Entity Type:Organization
Organization Name:DEEP ROCK CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:EDLUND
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-751-5910
Mailing Address - Street 1:1900 DIVISION ST W UNIT 7
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-6397
Mailing Address - Country:US
Mailing Address - Phone:218-751-5910
Mailing Address - Fax:218-444-5911
Practice Address - Street 1:1900 DIVISION ST W UNIT 7
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-6397
Practice Address - Country:US
Practice Address - Phone:218-751-5910
Practice Address - Fax:218-444-5911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty