Healthcare Provider Details

I. General information

NPI: 1346567609
Provider Name (Legal Business Name): HEALTHQUEST SPORTS INJURY AND CHIROPRACTIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2010
Last Update Date: 04/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1053 GRAND AVE 114
SAINT PAUL MN
55105-3022
US

IV. Provider business mailing address

1053 GRAND AVE 114
SAINT PAUL MN
55105-3022
US

V. Phone/Fax

Practice location:
  • Phone: 656-292-9247
  • Fax: 651-292-9257
Mailing address:
  • Phone: 656-292-9247
  • Fax: 651-292-9257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number5324
License Number StateMN

VIII. Authorized Official

Name: BRADLEY VERNON NORTHRUP
Title or Position: CHIROPRACTOR/OWNER
Credential: D.C.
Phone: 651-292-9247