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General NPI Number Information
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NPI Number | 1255661914
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Entity Type | Organization
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Legal Business Name | MINNESOTA PAIN RELIEF AND WELLNESS INSTITUTE PA
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Dates
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Enumeration Date | 12/31/2009
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Last Update Date | 11/24/2015
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Provider Practice Location Address
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Address Line | 2151 HAMLINE AVE N STE 111
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City | ROSEVILLE
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State | MN
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Zip | 55113-4236
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Country | US
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Telephone | 651-288-3098
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Fax | 763-210-6890
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Provider Business Mailing Address
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Address Line | 2151 HAMLINE AVE N STE 111
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City | ROSEVILLE
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State | MN
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Zip | 55113-4236
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Country | US
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Telephone | 651-288-3098
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Fax | 651-288-3781
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Authorized Official
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Title or Position | OWNER/ PROPRIETOR
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Name | DR. JASON JOHN WILSON
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Credential | D.C
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Telephone | 651-288-3098
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 3525
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License Number State | MN
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