Healthcare Provider Details

I. General information

NPI: 1023236874
Provider Name (Legal Business Name): ANNANDALE FAMILY AND SPORTS CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PARK STREET
ANNANDALE MN
55302
US

IV. Provider business mailing address

300 PARK STREET
ANNANDALE MN
55302
US

V. Phone/Fax

Practice location:
  • Phone: 320-274-3060
  • Fax: 320-274-5605
Mailing address:
  • Phone: 320-274-3060
  • Fax: 320-274-5605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number4274
License Number StateMN

VIII. Authorized Official

Name: DR. MITCHELL RALPH UECKER
Title or Position: DOCTOR-OWNER
Credential: D.C.
Phone: 320-274-3060