Healthcare Provider Details

I. General information

NPI: 1689017097
Provider Name (Legal Business Name): NORTHSIDE CHIROPRACTIC CLINIC LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2013
Last Update Date: 07/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3107 PENN AVE N
MINNEAPOLIS MN
55411-1123
US

IV. Provider business mailing address

3107 PENN AVE N
MINNEAPOLIS MN
55411-1123
US

V. Phone/Fax

Practice location:
  • Phone: 612-522-0440
  • Fax: 612-522-1816
Mailing address:
  • Phone: 612-522-0440
  • Fax: 612-522-1816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License Number2197
License Number StateMN

VIII. Authorized Official

Name: DR. GREG T OLSON
Title or Position: PRESIDENT/CEO
Credential: DC
Phone: 612-522-0440