MEDICARE: NEW BRIGHTON CHIROPRACTIC CLINIC, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	580	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	137L0NE	OTHER	MN	BCBS CLINIC ID

General Provider Information

NPI Number	:	1518963768
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW BRIGHTON CHIROPRACTIC CLINIC, P.A.

Provider Business Mailing Address
First Line	:	2216 COUNTY ROAD D W STE B
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55112-8505
Country	:	US
Telephone Number	:	651-636-4120
Fax Number	:	651-630-1069

Provider Business Practice Location Address
First Line	:	2216 COUNTY ROAD D W STE B
Second Line	:
City	:	NEW BRIGHTON
State	:	MN
Zip	:	55112-8505
Country	:	US
Telephone Number	:	651-636-4120
Fax Number	:	651-630-1069

Authorized Official
Title or Position	:	VP
Name	:	DR. CHRISTIAN JON KOLLAR
Credential	:	DC
Telephone Number	:	651-636-4120

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	08/16/2021

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