=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144502733
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REVELATION CHIROPRACTIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2011
-----------------------------------------------------
Last Update Date | 09/09/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8112 UPTON AVE S
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55431-1248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-267-9281
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8112 UPTON AVE S
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55431-1248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | DR. NICHOLAS RICHARD BAKER
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 612-267-9281
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 5186
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------