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NPI Code Detail

MEDICARE: JEWETT LAKE ENTERPRISES

MEDICARE: JEWETT LAKE ENTERPRISES
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
1261QH0100XHealth Service Clinic/Center

General Provider Information

NPI Number : 1831942242
Entity Type Code : Organization
Provider Name (Legal Business Name) : JEWETT LAKE ENTERPRISES
Provider Business Mailing Address
First Line : 17702 EDGEWATER RD NE
Second Line :
City : PINE CITY
State : MN
Zip : 55063-4763
Country : US
Telephone Number : 218-205-5728
Fax Number :
Provider Business Practice Location Address
First Line : 805 MAIN ST S
Second Line :
City : PINE CITY
State : MN
Zip : 55063-1660
Country : US
Telephone Number : 218-205-5728
Fax Number :
Authorized Official
Title or Position : CHIROPRACTOR
Name : DR. CLAY DANIELSON
Credential : DC
Telephone Number : 218-205-5728
Provider Enumeration Date : 04/08/2024
Last Update Date : 04/08/2024

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Directions to “JEWETT LAKE ENTERPRISES ” Practice Location

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