Provider Demographics
NPI:1770802019
Name:CHIROPRACTIC AND WELLNESS CENTER OF ALBERTVILLE PLLC
Entity type:Organization
Organization Name:CHIROPRACTIC AND WELLNESS CENTER OF ALBERTVILLE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:KONZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-497-0777
Mailing Address - Street 1:5676 LACENTRE AVE SUITE 204
Mailing Address - Street 2:
Mailing Address - City:ALBERTVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55301
Mailing Address - Country:US
Mailing Address - Phone:763-497-0777
Mailing Address - Fax:763-497-5377
Practice Address - Street 1:5676 LACENTRE AVENUE NE
Practice Address - Street 2:SUITE 202
Practice Address - City:ALBERTVILLE
Practice Address - State:MN
Practice Address - Zip Code:55301
Practice Address - Country:US
Practice Address - Phone:763-497-0777
Practice Address - Fax:763-497-5377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-26
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X, 111N00000X
MN5292111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty