Provider Demographics
NPI:1851594550
Name:WELLSPRING CHIROPRACTIC
Entity Type:Organization
Organization Name:WELLSPRING CHIROPRACTIC
Other - Org Name:WELLSPRING CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:WIEBE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-735-2201
Mailing Address - Street 1:7029 10TH ST N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5938
Mailing Address - Country:US
Mailing Address - Phone:651-735-2201
Mailing Address - Fax:651-739-0763
Practice Address - Street 1:7029 10TH ST N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-5938
Practice Address - Country:US
Practice Address - Phone:651-735-2201
Practice Address - Fax:651-739-0763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-08
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3361111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN233987000Medicaid
595R4WEOtherBLUE CROSS BLUE SHIELD
MN233987000Medicaid
C03642Medicare PIN