Healthcare Provider Details

I. General information

NPI: 1124478110
Provider Name (Legal Business Name): CHIROPRACTIC AND WELLNESS CENTER OF ALBERTVILLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5676 LACENTRE AVE. SUITE 204
ALBERTVILLE MN
55301
US

IV. Provider business mailing address

5676 LACENTRE AVE.
ALBERTVILLE MN
55301
US

V. Phone/Fax

Practice location:
  • Phone: 763-497-0777
  • Fax:
Mailing address:
  • Phone: 763-497-0777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5292
License Number StateMN

VIII. Authorized Official

Name: ANDREW KONZ
Title or Position: OWNER
Credential: D.C.
Phone: 763-497-0777