Healthcare Provider Details

I. General information

NPI: 1780851030
Provider Name (Legal Business Name): LELWICA CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 10/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31108 GOVERNMENT DR SUITE 108
PEQUOT LAKES MN
56472-1001
US

IV. Provider business mailing address

31108 GOVERNMENT DR SUITE 108
PEQUOT LAKES MN
56472-1001
US

V. Phone/Fax

Practice location:
  • Phone: 218-568-5648
  • Fax: 218-568-5698
Mailing address:
  • Phone: 218-568-5648
  • Fax: 218-568-5698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. SHANNON TROY JONES
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 218-568-5648