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General NPI Number Information
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NPI Number | 1972529634
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Entity Type | Organization
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Legal Business Name | ELITE CHIROPRACTIC-NORTH ST. PAUL
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Dates
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Enumeration Date | 07/14/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2597 7TH AVE E
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City | SAINT PAUL
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State | MN
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Zip | 55109-3104
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Country | US
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Telephone | 651-777-1710
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Fax | 651-777-9108
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Provider Business Mailing Address
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Address Line | 20456 LAKE RIDGE DR
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City | PRIOR LAKE
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State | MN
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Zip | 55372-7805
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Country | US
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Telephone | 952-492-5914
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Fax | 952-492-5913
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Authorized Official
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Title or Position | OWNER, PRESIDENT OF LLC
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Name | DR. BRADLEY DALE WILDBERG
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Credential | D.C.
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Telephone | 952-492-5914
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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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