Provider Demographics
NPI:1972837649
Name:COLLYARD CHIROPRACTIC P A
Entity Type:Organization
Organization Name:COLLYARD CHIROPRACTIC P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:COLLYARD-GLINSEK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-274-0377
Mailing Address - Street 1:510 FREEPORT AVE NW STE F
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-3007
Mailing Address - Country:US
Mailing Address - Phone:763-274-0377
Mailing Address - Fax:763-633-0366
Practice Address - Street 1:510 FREEPORT AVE NW STE F
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-3007
Practice Address - Country:US
Practice Address - Phone:763-274-0377
Practice Address - Fax:763-633-0366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-28
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDC 4090261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN966407600Medicaid
MNU86940Medicare UPIN
MN350002464Medicare PIN