Provider Demographics
NPI:1245675511
Name:LAKE NICOLLET CLINIC, PA
Entity type:Organization
Organization Name:LAKE NICOLLET CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ARTUR
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:GUZHAGIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:612-259-7570
Mailing Address - Street 1:PO BOX 80808
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-8808
Mailing Address - Country:US
Mailing Address - Phone:612-259-7570
Mailing Address - Fax:612-886-3427
Practice Address - Street 1:ONE WEST LAKE STREET
Practice Address - Street 2:SUITE 195
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-3362
Practice Address - Country:US
Practice Address - Phone:612-259-7570
Practice Address - Fax:612-886-3427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-01
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1176111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty