Healthcare Provider Details

I. General information

NPI: 1760660427
Provider Name (Legal Business Name): GREEN LAKE CHIROPRACTIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 06/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 5TH ST SW
WILLMAR MN
56201-3211
US

IV. Provider business mailing address

205 5TH ST SW
WILLMAR MN
56201-3211
US

V. Phone/Fax

Practice location:
  • Phone: 320-214-0044
  • Fax: 320-214-0045
Mailing address:
  • Phone: 320-214-0044
  • Fax: 320-214-0045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number4176
License Number StateMN

VIII. Authorized Official

Name: DR. JON D. HAEFNER
Title or Position: PRESIDENT
Credential: D.C.
Phone: 320-214-0044