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General NPI Number Information
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NPI Number | 1912304627
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Entity Type | Organization
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Legal Business Name | AUGUSTINE SPORTS AND FAMILY CHIROPRACTIC LLC
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Dates
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Enumeration Date | 11/24/2014
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Last Update Date | 04/27/2015
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Provider Practice Location Address
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Address Line | 1025 SELBY AVE SUITE 101
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City | SAINT PAUL
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State | MN
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Zip | 55104-6533
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Country | US
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Telephone | 651-228-9000
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Fax | 651-224-2806
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Provider Business Mailing Address
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Address Line | 1025 SELBY AVE SUITE 101
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City | SAINT PAUL
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State | MN
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Zip | 55104-6533
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Country | US
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Telephone | 651-228-9000
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Fax | 651-224-2806
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | TRISHA LEE AUGUSTINE
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Credential | D.C.
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Telephone | 952-220-2857
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 5983
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License Number State | MN
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