=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265702690
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTH QUEST FAMILY CHIROPRACTIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2012
-----------------------------------------------------
Last Update Date | 01/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 213 LABREE AVE N SUITE 101
-----------------------------------------------------
City | THIEF RIVER FALLS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56701-2022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-212-3294
-----------------------------------------------------
Fax | 855-245-5546
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 213 LABREE AVE N SUITE 101
-----------------------------------------------------
City | THIEF RIVER FALLS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56701-2022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-212-3294
-----------------------------------------------------
Fax | 855-245-5546
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR/OWNER
-----------------------------------------------------
Name | DR. STEVEN R WISETH
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 701-212-3294
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 5506
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------