Provider Demographics
NPI:1295747889
Name:BIG LAKE SPINE & SPORT, PA
Entity type:Organization
Organization Name:BIG LAKE SPINE & SPORT, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BILL
Authorized Official - Middle Name:E
Authorized Official - Last Name:MICKLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-260-8401
Mailing Address - Street 1:1260 HIGHWAY 25 S
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-8921
Mailing Address - Country:US
Mailing Address - Phone:763-260-8401
Mailing Address - Fax:763-263-5900
Practice Address - Street 1:1260 HIGHWAY 25 S
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8921
Practice Address - Country:US
Practice Address - Phone:763-260-8401
Practice Address - Fax:763-295-2208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3548111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC04140Medicare ID - Type Unspecified