Provider Demographics
NPI:1770727703
Name:PURE CHIROPRACTIC & REHAB PC
Entity type:Organization
Organization Name:PURE CHIROPRACTIC & REHAB PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:FELDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-893-7873
Mailing Address - Street 1:3227 42ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-6633
Mailing Address - Country:US
Mailing Address - Phone:701-461-9030
Mailing Address - Fax:701-239-7088
Practice Address - Street 1:300 45TH ST S STE 315
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6511
Practice Address - Country:US
Practice Address - Phone:701-893-7873
Practice Address - Fax:701-893-7876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND719111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18577Medicaid
MN60602000Medicaid
MN60602000Medicaid