Provider Demographics
NPI:1336454305
Name:LUNDGREN CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:LUNDGREN CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNDGREN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:406-586-1984
Mailing Address - Street 1:662 S FERGUSON AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-6492
Mailing Address - Country:US
Mailing Address - Phone:406-586-1984
Mailing Address - Fax:406-551-2049
Practice Address - Street 1:662 S FERGUSON AVE STE 1
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-6492
Practice Address - Country:US
Practice Address - Phone:406-586-1984
Practice Address - Fax:406-551-2049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-13
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT708111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
M011000442OtherMEDICARE PTAN