Healthcare Provider Details

I. General information

NPI: 1013355478
Provider Name (Legal Business Name): WAYPOINT MINNESOTA SPORTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2013
Last Update Date: 06/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9325 UPLAND LN N SUITE 230
MAPLE GROVE MN
55369-4200
US

IV. Provider business mailing address

9325 UPLAND LN N SUITE 230
MAPLE GROVE MN
55369-4200
US

V. Phone/Fax

Practice location:
  • Phone: 763-315-0466
  • Fax:
Mailing address:
  • Phone: 763-315-0466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: MR. ANTHONY DIMARCO
Title or Position: CHIEF OPERATING OFFICER / SECRETARY
Credential:
Phone: 917-434-9669