Provider Demographics
NPI:1902997703
Name:BOONE FAMILY CHIROPRACTIC AND WELLNESS, PLC
Entity Type:Organization
Organization Name:BOONE FAMILY CHIROPRACTIC AND WELLNESS, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:STACY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOONE-VIKINGSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-232-4303
Mailing Address - Street 1:12630 43RD ST NE
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAEL
Mailing Address - State:MN
Mailing Address - Zip Code:55376-8432
Mailing Address - Country:US
Mailing Address - Phone:763-232-4303
Mailing Address - Fax:
Practice Address - Street 1:12630 43RD ST NE
Practice Address - Street 2:
Practice Address - City:SAINT MICHAEL
Practice Address - State:MN
Practice Address - Zip Code:55376-8432
Practice Address - Country:US
Practice Address - Phone:763-232-4303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4815111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN09N81BOOtherBLUE CROSS BLUE SHIELD OF MINNESOTA
MN701555OtherOPTIMUM HEALTH
MN44-03165OtherMEDICA
MN634620200Medicaid
MN09N81BOOtherBLUE CROSS BLUE SHIELD OF MINNESOTA