NPIMap

Organization Active NPI

Eagle Creek Wellness Center LLC

  • Chiropractor
  • Prior Lake, MN
National Provider Identifier
1366631244
Registry record updated Mar 2, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
ChiropractorTaxonomy code 111N00000X
License
DC3496 Issued in MN
Legal business name
EAGLE CREEK WELLNESS CENTER LLC
Practice address
14180 Commerce Ave NE
Prior Lake, MN 55372-1483
Phone
(952) 447-3395
Fax
(952) 447-3396
NPI assigned
Oct 17, 2007
Last updated
Mar 2, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 2, 2020

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

Authorized official

Name
Nicholas David Anderson
Title
Owner
Phone
(952) 447-9935

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Chiropractor 111N00000X DC3496 MN Primary

Addresses

Primary practice location

14180 Commerce Ave NE
Prior Lake, MN 55372-1483

Mailing address

14180 Commerce Ave NE
Prior Lake, MN 55372-1483
Phone (952) 447-3395

Other identifiers 2

IdentifierTypeStateIssuer
271223700MedicaidMN
747637000MedicaidMN

National Provider Directory

National Provider Directory

Locations

14180 Commerce Ave NE
Prior Lake, MN 55372
Phone (952) 447-3395

14180 Commerce Ave NE
Ste 100
Prior Lake, MN 55372
Phone (952) 447-3395

14180 Commerce Ave NE
Ste 110
Prior Lake, MN 55372

Practitioners & affiliated clinicians

Practitioners 6

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.

NPI Registry JSON

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

{
    "created_epoch": "1192579200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1583107200000",
    "number": "1366631244",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "14180 COMMERCE AVE NE",
            "city": "PRIOR LAKE",
            "state": "MN",
            "postal_code": "553721483",
            "telephone_number": "952-447-3395",
            "fax_number": "952-447-3396"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "14180 COMMERCE AVE NE",
            "city": "PRIOR LAKE",
            "state": "MN",
            "postal_code": "553721483",
            "telephone_number": "952-447-3395",
            "fax_number": "952-447-3396"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAGLE CREEK WELLNESS CENTER LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-10-17",
        "last_updated": "2020-03-02",
        "certification_date": "2020-03-02",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "NICHOLAS",
        "authorized_official_middle_name": "DAVID",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "952-447-9935"
    },
    "taxonomies": [
        {
            "code": "111N00000X",
            "taxonomy_group": "",
            "desc": "Chiropractor",
            "state": "MN",
            "license": "DC3496",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "271223700",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "747637000",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Prior Lake, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 2, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.