Inner Light Chiropractic, P.a.

Primary specialty

ChiropractorTaxonomy code 111N00000X

License

4717 Issued in MN

Legal business name

INNER LIGHT CHIROPRACTIC, P.A.

Practice address

4630 97TH Ave N
Brooklyn Park, MN 55443

Phone

(763) 486-3945

NPI assigned

Jan 26, 2006

Organization subpart

No

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

Authorized official

Name

Dr. Russell S. Derhak, D.C.NPI 1194856583

Title

President

Phone

(612) 749-4600

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in MN

Enrollment records 1

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Russell S Derhak, D.C.

  • Chiropractor
  • Brooklyn Park, MN
  • NPI 1194856583
  Medicare reassignment NPD Authorized official

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

{
    "created_epoch": "1138233600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1396715686",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4630 97TH AVE N",
            "city": "BROOKLYN PARK",
            "state": "MN",
            "postal_code": "55443",
            "telephone_number": "763-486-3945"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4630 97TH AVE N",
            "city": "BROOKLYN PARK",
            "state": "MN",
            "postal_code": "55443",
            "telephone_number": "763-486-3945"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INNER LIGHT CHIROPRACTIC, P.A.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-01-26",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "DERHAK",
        "authorized_official_first_name": "RUSSELL",
        "authorized_official_middle_name": "S.",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "612-749-4600",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.C."
    },
    "taxonomies": [
        {
            "code": "111N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Chiropractor",
            "state": "MN",
            "license": "4717",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• All providers in Brooklyn Park, MN
• Chiropractor in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; 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.