Provider Demographics
NPI:1912051756
Name:EAST CENTRAL CHIROPRACTIC CLINIC, P.A.
Entity Type:Organization
Organization Name:EAST CENTRAL CHIROPRACTIC CLINIC, P.A.
Other - Org Name:TOTAL HEALTH CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:NYBLOM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-689-1110
Mailing Address - Street 1:911 MAIN ST S
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008-2125
Mailing Address - Country:US
Mailing Address - Phone:763-689-1110
Mailing Address - Fax:763-552-1110
Practice Address - Street 1:911 MAIN ST S
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-2125
Practice Address - Country:US
Practice Address - Phone:763-689-1110
Practice Address - Fax:763-552-1110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6C485EAOtherCLINIC BCBS NUMBER
MNC03230Medicare PIN