Provider Demographics
NPI:1790529071
Name:JEWETT LAKE ENTERPRISES INC
Entity type:Organization
Organization Name:JEWETT LAKE ENTERPRISES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAY
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-205-5728
Mailing Address - Street 1:423 FRONT STREET N
Mailing Address - Street 2:PO 114
Mailing Address - City:BARNESVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56514
Mailing Address - Country:US
Mailing Address - Phone:218-205-5728
Mailing Address - Fax:
Practice Address - Street 1:423 FRONT ST N
Practice Address - Street 2:
Practice Address - City:BARNESVILLE
Practice Address - State:MN
Practice Address - Zip Code:56514-3115
Practice Address - Country:US
Practice Address - Phone:218-205-5728
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service