NPIMap

Organization Active NPI

Big Lake Spine & Sport, PA

Doing business as Great River Spine & Sport

  • Chiropractor
  • Monticello, MN
National Provider Identifier
1295747889
Registry record updated Oct 18, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
ChiropractorTaxonomy code 111N00000X
License
3548 Issued in MN
Legal business name
BIG LAKE SPINE & SPORT, PA
Doing business as
Great River Spine & Sport
Practice address
1260 Highway 25 S
Monticello, MN 55362-8921
Phone
(763) 260-8401
Fax
(763) 295-2208
NPI assigned
Aug 12, 2006
Last updated
Oct 18, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 18, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Bill E Mickle, DCNPI 1790907434
Title
Owner
Phone
(763) 260-8401

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
ChiropractorGroup: 193200000X MULTI-SPECIALTY GROUP 111N00000X 3548 MN Primary

Addresses

Primary practice location

1260 Highway 25 S
Monticello, MN 55362-8921

Mailing address

1260 Highway 25 S
Monticello, MN 55362-8921
Phone (763) 260-8401

Other practice location 1

751 Rose Dr Ste 108
Big Lake, MN 55309-8870
Phone (763) 260-8401 ext. 2

Other names 1

  • Great River Spine & Sport Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20051215000628 MN Part B Supplier - Clinic/Group Practice 3971524182 Receives reassigned benefits from 2 practitioners
Practice locations: Big Lake, MN; Monticello, MN

National Provider Directory

National Provider Directory

Locations

13952 1St St
Becker, MN 55308
Phone (763) 263-4848

135 Sandberg Rd
Monticello, MN 55362
Phone (763) 295-3355

Practitioners & affiliated clinicians

Practitioners 31

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 31

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1155340800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1571356800000",
    "number": "1295747889",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1260 HIGHWAY 25 S",
            "city": "MONTICELLO",
            "state": "MN",
            "postal_code": "553628921",
            "telephone_number": "763-260-8401",
            "fax_number": "763-263-5900"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1260 HIGHWAY 25 S",
            "city": "MONTICELLO",
            "state": "MN",
            "postal_code": "553628921",
            "telephone_number": "763-260-8401",
            "fax_number": "763-295-2208"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "751 Rose Dr Ste 108",
            "address_purpose": "LOCATION",
            "city": "Big Lake",
            "state": "MN",
            "postal_code": "553098870",
            "country_code": "US",
            "telephone_number": "763-260-8401 x2",
            "fax_number": "763-273-8921",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "BIG LAKE SPINE & SPORT, PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-12",
        "last_updated": "2019-10-18",
        "status": "A",
        "authorized_official_last_name": "MICKLE",
        "authorized_official_first_name": "BILL",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "763-260-8401",
        "authorized_official_credential": "DC"
    },
    "taxonomies": [
        {
            "code": "111N00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Chiropractor",
            "state": "MN",
            "license": "3548",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Great River Spine & Sport",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Great River Spine & Sport",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Monticello, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 18, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.