MEDICARE: VITALIGN SPINE CLINIC PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1043964471
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITALIGN SPINE CLINIC PLLC

Provider Business Mailing Address
First Line	:	7835 MAIN ST N STE 230
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55369-7072
Country	:	US
Telephone Number	:	763-600-6450
Fax Number	:

Provider Business Practice Location Address
First Line	:	7835 MAIN ST N STE 230
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55369-7072
Country	:	US
Telephone Number	:	763-600-6450
Fax Number	:

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	DR. CHAD HERRBOLDT
Credential	:	DC
Telephone Number	:	763-600-6450

Provider Enumeration Date	:	02/04/2022
Last Update Date	:	05/09/2022

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