Organization
EAGLE CREEK WELLNESS CENTER LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
NICHOLAS DAVID ANDERSON (OWNER)
(952) 447-9935
Entity
Organization
Contact information
Practice address
14180 COMMERCE AVE NE, PRIOR LAKE, MN 55372-1483
(952) 447-3395
(952) 447-3396
Mailing address
14180 COMMERCE AVE NE, PRIOR LAKE, MN 55372-1483
(952) 447-3395
(952) 447-3396
Taxonomy
Speciality
Code
Description
License number
State
111N00000X
Chiropractor
Primary
DC3496
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
271223700
—
MN
05
—
747637000
—
MN
Enumeration date
10/17/2007
Last updated
03/02/2020
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