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General NPI Number Information
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NPI Number | 1316989817
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Entity Type | Organization
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Legal Business Name | CHIROPRACTIC SPORT & SPINAL REHAB PA
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Dates
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Enumeration Date | 06/11/2006
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Last Update Date | 03/26/2013
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Provider Practice Location Address
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Address Line | 201 LAKE ST NW SUITE G
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City | WARROAD
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State | MN
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Zip | 56763-2116
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Country | US
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Telephone | 218-386-1930
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Fax | 218-386-1921
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Provider Business Mailing Address
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Address Line | 201 LAKE ST NW SUITE G, PO BOX 930
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City | WARROAD
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State | MN
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Zip | 56763-2116
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Country | US
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Telephone | 218-386-1930
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Fax | 218-386-1921
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Authorized Official
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Title or Position | OWNER/CHIROPRACTOR
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Name | DR. LYLE RICHARD ERICKSON
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Credential | D.C.
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Telephone | 218-386-1930
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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 | 3705
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License Number State | MN
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