Provider Demographics
NPI:1255407136
Name:BIRCH LAKE CHIROPRACTIC CLINIC, LLC
Entity type:Organization
Organization Name:BIRCH LAKE CHIROPRACTIC CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-429-5329
Mailing Address - Street 1:4635 WHITE BEAR PKWY
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3300
Mailing Address - Country:US
Mailing Address - Phone:651-429-5329
Mailing Address - Fax:651-429-2759
Practice Address - Street 1:4635 WHITE BEAR PKWY
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3300
Practice Address - Country:US
Practice Address - Phone:651-429-5329
Practice Address - Fax:651-429-2759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN751111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
273GOBIOtherBCBS - CLINIC #
231600OtherACN
6763511-00OtherMHCP
C04137Medicare ID - Type UnspecifiedMEDICARE CLINIC
U62879Medicare UPIN