Provider Demographics
NPI:1861819989
Name:TRADITIONALLY HEALTHY
Entity Type:Organization
Organization Name:TRADITIONALLY HEALTHY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:612-382-7408
Mailing Address - Street 1:9744 WOODRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347-4249
Mailing Address - Country:US
Mailing Address - Phone:612-382-7497
Mailing Address - Fax:
Practice Address - Street 1:1211 JACKSON ST NE
Practice Address - Street 2:SUITE 121
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413
Practice Address - Country:US
Practice Address - Phone:612-382-7408
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3928111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty