Healthcare Provider Details

I. General information

NPI: 1447807813
Provider Name (Legal Business Name): S GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 01/20/2020
Certification Date: 01/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 HIGHWAY 169 N STE 301
NEW HOPE MN
55428-4019
US

IV. Provider business mailing address

4900 HIGHWAY 169 N STE 301
NEW HOPE MN
55428-4019
US

V. Phone/Fax

Practice location:
  • Phone: 763-496-7871
  • Fax:
Mailing address:
  • Phone: 763-496-7871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. ETHAN LEE SKOG
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 763-496-7871