Provider Demographics
NPI:1770792400
Name:PREMIER HEALTH OF ROSEVILLE, LTD
Entity type:Organization
Organization Name:PREMIER HEALTH OF ROSEVILLE, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:KOEHLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-487-2198
Mailing Address - Street 1:1601 LARPENTEUR AVE
Mailing Address - Street 2:
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:651-487-2198
Mailing Address - Fax:651-646-0283
Practice Address - Street 1:1601 LARPENTEUR AVE
Practice Address - Street 2:
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55113
Practice Address - Country:US
Practice Address - Phone:651-487-2198
Practice Address - Fax:651-646-0283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN761153600Medicaid
MNC01419Medicare UPIN