Provider Demographics
NPI:1851463475
Name:NOKOMIS CHIROPRACTIC CENTER P.A.
Entity Type:Organization
Organization Name:NOKOMIS CHIROPRACTIC CENTER P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:612-822-0149
Mailing Address - Street 1:5313 LYNDALE AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-1229
Mailing Address - Country:US
Mailing Address - Phone:612-822-0149
Mailing Address - Fax:612-822-7441
Practice Address - Street 1:5313 LYNDALE AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55419-1229
Practice Address - Country:US
Practice Address - Phone:612-822-0149
Practice Address - Fax:612-822-7441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2735111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN71102NOOtherBCBS CLINIC ID
MNC03272Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID