Healthcare Provider Details

I. General information

NPI: 1407603921
Provider Name (Legal Business Name): SAGE FAMILY CHIROPRACTIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2024
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4711 45TH ST S
FARGO ND
58104-5300
US

IV. Provider business mailing address

PO BOX 9291
FARGO ND
58106-9291
US

V. Phone/Fax

Practice location:
  • Phone: 605-868-0565
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111NP0017X
TaxonomyPediatric Chiropractor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: ASHLEY ANN UECKERT
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 701-300-0839