Healthcare Provider Details

I. General information

NPI: 1780800524
Provider Name (Legal Business Name): BACK ON TRACK REHABILITATION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1246 32ND AVE N
SAINT CLOUD MN
56303-1649
US

IV. Provider business mailing address

1246 32ND AVE N
SAINT CLOUD MN
56303-1649
US

V. Phone/Fax

Practice location:
  • Phone: 320-230-8920
  • Fax: 320-230-8922
Mailing address:
  • Phone: 320-230-8920
  • Fax: 320-230-8922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number4468
License Number StateMN

VIII. Authorized Official

Name: DR. MELISSA M LOIDOLT
Title or Position: PRESIDENT
Credential: DC
Phone: 320-230-8920