Provider Demographics
NPI:1730372509
Name:DYNAMIC BALANCE PC
Entity type:Organization
Organization Name:DYNAMIC BALANCE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CRIPE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-295-2262
Mailing Address - Street 1:212 CEDAR ST
Mailing Address - Street 2:PO BOX 1638
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-8598
Mailing Address - Country:US
Mailing Address - Phone:763-295-2262
Mailing Address - Fax:763-295-6282
Practice Address - Street 1:212 CEDAR ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8598
Practice Address - Country:US
Practice Address - Phone:763-295-2262
Practice Address - Fax:763-295-6282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4170111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN422L0MOOtherBCBS
MN641442OtherACN
MN422L1MOOtherBCBS
MNU88667Medicare UPIN
MN422L1MOOtherBCBS