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General NPI Number Information
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NPI Number | 1568533909
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Entity Type | Organization
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Legal Business Name | CRYSTAL-NEW HOPE CHIROPRACTIC CLINIC P.A.
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Dates
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Enumeration Date | 11/09/2006
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Last Update Date | 01/04/2010
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Provider Practice Location Address
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Address Line | 6014 SHINGLE CREEK PKWY
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City | BROOKLYN CENTER
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State | MN
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Zip | 55430-2316
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Country | US
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Telephone | 763-533-6775
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Fax |
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Provider Business Mailing Address
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Address Line | 6014 SHINGLE CREEK PKWY
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City | BROOKLYN CENTER
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State | MN
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Zip | 55430-2316
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Country | US
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Telephone | 763-533-6775
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARTIN VON IDERSTINE
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Credential | DC
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Telephone | 763-533-6775
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NX0800X
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Taxonomy Name | Orthopedic Chiropractor
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License Number | 1581
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License Number State | MN
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