Healthcare Provider Details

I. General information

NPI: 1598912818
Provider Name (Legal Business Name): INTERSTATE CHIROPRACTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 10/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11276 210 ST W STE 104
LAKEVILLE MN
55044
US

IV. Provider business mailing address

11276 210 ST W STE 104
LAKEVILLE MN
55044
US

V. Phone/Fax

Practice location:
  • Phone: 952-469-3443
  • Fax: 952-469-3473
Mailing address:
  • Phone: 952-469-3443
  • Fax: 952-469-3473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4367
License Number StateMN

VIII. Authorized Official

Name: DR. ERIC LEIGH TESSMER
Title or Position: OWNER
Credential: DC
Phone: 952-469-3443