Provider Demographics
NPI:1851464036
Name:ALLIED CHIROPRACTIC CENTER OF EAGAN PA.
Entity Type:Organization
Organization Name:ALLIED CHIROPRACTIC CENTER OF EAGAN PA.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO,CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:612-709-3104
Mailing Address - Street 1:3916 W 113TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55437-3503
Mailing Address - Country:US
Mailing Address - Phone:612-709-3104
Mailing Address - Fax:952-884-0852
Practice Address - Street 1:3916 W 113TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55437-3503
Practice Address - Country:US
Practice Address - Phone:612-709-3104
Practice Address - Fax:952-884-0852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2493111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty