Healthcare Provider Details

I. General information

NPI: 1427447432
Provider Name (Legal Business Name): CLUB WEST CHIROPRACTIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2015
Last Update Date: 02/26/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10950 CLUB WEST PKWY STE 190
BLAINE MN
55449-5862
US

IV. Provider business mailing address

10950 CLUB WEST PKWY STE 190
BLAINE MN
55449-5862
US

V. Phone/Fax

Practice location:
  • Phone: 763-400-4940
  • Fax:
Mailing address:
  • Phone: 763-400-4940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: ALYCEAN MARYRAE BERGH
Title or Position: VP
Credential: DC
Phone: 763-400-4940