Provider Demographics
NPI:1841536323
Name:SHOREVIEW SPINE AND SPORT FAMILY CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:SHOREVIEW SPINE AND SPORT FAMILY CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/TREASURER/SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:HENDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-205-0387
Mailing Address - Street 1:3434 LEXINGTON AVE N
Mailing Address - Street 2:SUITE 900
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-8069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3434 LEXINGTON AVE N
Practice Address - Street 2:SUITE 900
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-8069
Practice Address - Country:US
Practice Address - Phone:651-447-2468
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-02
Last Update Date:2013-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5736111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty