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General NPI Number Information
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NPI Number | 1497052898
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Entity Type | Organization
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Legal Business Name | FISHTRAP LAKE ENTERPRISES INC.
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Dates
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Enumeration Date | 02/21/2011
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Last Update Date | 03/06/2012
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Provider Practice Location Address
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Address Line | 3701 HIGHWAY 13 W
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City | BURNSVILLE
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State | MN
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Zip | 55337-1721
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Country | US
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Telephone | 952-895-1120
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Fax | 952-895-5377
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Provider Business Mailing Address
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Address Line | 3701 HIGHWAY 13 W
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City | BURNSVILLE
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State | MN
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Zip | 55337-1721
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Country | US
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Telephone | 952-895-1120
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Fax | 952-895-5377
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Authorized Official
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Title or Position | CEO
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Name | DR. MICHAEL EDWARD NOVAK
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Credential | D.C.
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Telephone | 952-895-1120
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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 |
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License Number State |
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