Provider Demographics
NPI:1740318146
Name:UNITED CHIROPRACTIC CLINIC
Entity type:Organization
Organization Name:UNITED CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC, DAAPM, DACBN
Authorized Official - Phone:651-642-1110
Mailing Address - Street 1:995 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4796
Mailing Address - Country:US
Mailing Address - Phone:651-642-1110
Mailing Address - Fax:651-642-1113
Practice Address - Street 1:995 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 101
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4796
Practice Address - Country:US
Practice Address - Phone:651-642-1110
Practice Address - Fax:651-642-1113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3532111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5C969PHOtherBCBS-MN
MN232018OtherACN
MN5C969PHOtherBCBS-MN