=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861557217
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INGBRETSON CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1752 LEXINGTON AVE N
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55113-6516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-487-5950
-----------------------------------------------------
Fax | 651-487-6016
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8942 WOODHALL CIR
-----------------------------------------------------
City | BROOKLYN PARK
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55443-1637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-493-0487
-----------------------------------------------------
Fax | 763-493-0487
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. HEATHER ELISE INGBRETSON
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 763-226-1129
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 4722
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------