Provider Demographics
NPI:1700163573
Name:PRIOR LAKE SPINE HEALTH & INJURY CENTER, PLLC
Entity Type:Organization
Organization Name:PRIOR LAKE SPINE HEALTH & INJURY CENTER, PLLC
Other - Org Name:PRIOR LAKE SPINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:R
Authorized Official - Last Name:RICKERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-226-5100
Mailing Address - Street 1:16197 MAIN AVE SE
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-1704
Mailing Address - Country:US
Mailing Address - Phone:952-226-5100
Mailing Address - Fax:952-516-5240
Practice Address - Street 1:16197 MAIN AVE SE
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-1704
Practice Address - Country:US
Practice Address - Phone:952-226-5100
Practice Address - Fax:952-516-5240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-08
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5230111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty