Provider Demographics
NPI:1023434164
Name:SG CHIROPRACTIC PC
Entity type:Organization
Organization Name:SG CHIROPRACTIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:LILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-533-4777
Mailing Address - Street 1:93 20TH ST NE
Mailing Address - Street 2:
Mailing Address - City:STEWARTVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55976-8421
Mailing Address - Country:US
Mailing Address - Phone:507-533-4777
Mailing Address - Fax:507-533-4778
Practice Address - Street 1:93 20TH ST NE
Practice Address - Street 2:
Practice Address - City:STEWARTVILLE
Practice Address - State:MN
Practice Address - Zip Code:55976-8421
Practice Address - Country:US
Practice Address - Phone:507-533-4777
Practice Address - Fax:507-533-4778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-13
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4424111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3366567Medicaid