Provider Demographics
NPI:1922362813
Name:COUNTRY CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:COUNTRY CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEZLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PUETZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:320-679-3734
Mailing Address - Street 1:4505 STATE HIGHWAY 23
Mailing Address - Street 2:
Mailing Address - City:BROOK PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55007-2112
Mailing Address - Country:US
Mailing Address - Phone:320-679-3734
Mailing Address - Fax:320-679-5211
Practice Address - Street 1:4505 STATE HIGHWAY 23
Practice Address - Street 2:
Practice Address - City:BROOK PARK
Practice Address - State:MN
Practice Address - Zip Code:55007-2112
Practice Address - Country:US
Practice Address - Phone:320-679-3734
Practice Address - Fax:320-679-5211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4586111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty