Healthcare Provider Details

I. General information

NPI: 1902997703
Provider Name (Legal Business Name): BOONE FAMILY CHIROPRACTIC AND WELLNESS, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 11/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12630 43RD ST NE
SAINT MICHAEL MN
55376-8432
US

IV. Provider business mailing address

12630 43RD ST NE
SAINT MICHAEL MN
55376-8432
US

V. Phone/Fax

Practice location:
  • Phone: 763-232-4303
  • Fax:
Mailing address:
  • Phone: 763-232-4303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4815
License Number StateMN

VIII. Authorized Official

Name: DR. STACY M BOONE-VIKINGSON
Title or Position: CEO
Credential: D.C.
Phone: 763-232-4303