Healthcare Provider Details

I. General information

NPI: 1699054213
Provider Name (Legal Business Name): EAGLE VALLEY CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2011
Last Update Date: 08/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 PEMBROKE AVE S
WABASHA MN
55981-1243
US

IV. Provider business mailing address

176 PEMBROKE AVE S
WABASHA MN
55981-1243
US

V. Phone/Fax

Practice location:
  • Phone: 651-565-4863
  • Fax: 651-565-4893
Mailing address:
  • Phone: 651-565-4863
  • Fax: 651-565-4893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number4754-012
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number5533
License Number StateMN

VIII. Authorized Official

Name: DR. JESSIN SKOUG
Title or Position: OWNER
Credential: DC
Phone: 651-565-4863