Healthcare Provider Details

I. General information

NPI: 1336461664
Provider Name (Legal Business Name): KEYSTONE CHIROPRACTIC HEALTH CENTRE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2010
Last Update Date: 05/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 COMMERCE BLVD
MOUND MN
55364-1493
US

IV. Provider business mailing address

2305 COMMERCE BLVD
MOUND MN
55364-1493
US

V. Phone/Fax

Practice location:
  • Phone: 952-471-2560
  • Fax: 952-471-2465
Mailing address:
  • Phone: 952-471-2560
  • Fax: 952-471-2465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5307
License Number StateMN

VIII. Authorized Official

Name: DR. JAYME LYNN CLAYTON
Title or Position: PRESIDENT
Credential: DC
Phone: 952-471-2560