Healthcare Provider Details

I. General information

NPI: 1669811295
Provider Name (Legal Business Name): VAAGENES CHIROPRACTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2013
Last Update Date: 06/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 HIGHWAY 96 W SUITE 160
SHOREVIEW MN
55126-1996
US

IV. Provider business mailing address

2508 HIGHWAY 70 PO BOX 385
BRAHAM MN
55006-3759
US

V. Phone/Fax

Practice location:
  • Phone: 651-415-0446
  • Fax: 651-415-0447
Mailing address:
  • Phone: 651-415-0446
  • Fax: 651-415-0447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number3144
License Number StateMN

VIII. Authorized Official

Name: DR. TIMOTHY JON VAAGENES SR.
Title or Position: OWNER
Credential: DC
Phone: 651-415-0446