Provider Demographics
NPI:1649489493
Name:WILLOWBRIDGE, INC.
Entity type:Organization
Organization Name:WILLOWBRIDGE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANLAUF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-552-6161
Mailing Address - Street 1:4 ENTERPRISE AVE NE STE 1
Mailing Address - Street 2:
Mailing Address - City:ISANTI
Mailing Address - State:MN
Mailing Address - Zip Code:55040-6814
Mailing Address - Country:US
Mailing Address - Phone:763-552-6161
Mailing Address - Fax:763-237-3254
Practice Address - Street 1:4 ENTERPRISE AVE NE STE 1
Practice Address - Street 2:
Practice Address - City:ISANTI
Practice Address - State:MN
Practice Address - Zip Code:55040-6814
Practice Address - Country:US
Practice Address - Phone:763-552-6161
Practice Address - Fax:763-237-3254
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLOWBRIDGE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-21
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN171100000X
225700000X, 111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty