Provider Demographics
NPI:1912304627
Name:AUGUSTINE SPORTS AND FAMILY CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:AUGUSTINE SPORTS AND FAMILY CHIROPRACTIC LLC
Other - Org Name:GRAND HEALTH CHIROPRACTIC AND WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TRISHA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:AUGUSTINE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-220-2857
Mailing Address - Street 1:1025 SELBY AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6533
Mailing Address - Country:US
Mailing Address - Phone:651-228-9000
Mailing Address - Fax:651-224-2806
Practice Address - Street 1:1025 SELBY AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6533
Practice Address - Country:US
Practice Address - Phone:651-228-9000
Practice Address - Fax:651-224-2806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-24
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5983261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center