Healthcare Provider Details

I. General information

NPI: 1790932390
Provider Name (Legal Business Name): EAGLE TRACE WELLNESS CENTER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2008
Last Update Date: 08/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12002 COUNTY ROAD 11
BURNSVILLE MN
55337-3016
US

IV. Provider business mailing address

12002 COUNTY ROAD 11
BURNSVILLE MN
55337-3016
US

V. Phone/Fax

Practice location:
  • Phone: 952-808-2922
  • Fax: 952-808-2910
Mailing address:
  • Phone: 952-808-2922
  • Fax: 952-808-2910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5077
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5104
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number832
License Number StateMN

VIII. Authorized Official

Name: DR. ELISA MARIE KENSINGER
Title or Position: VICE PRESIDENT, SECRETARY, TREASURE
Credential: D.C.
Phone: 952-808-2922