NPIMap

Organization Active NPI

Eagle Trace Wellness Center, PA

  • Chiropractor
  • Burnsville, MN
National Provider Identifier
1790932390
Registry record updated Aug 26, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
ChiropractorTaxonomy code 111N00000X
License
5077 Issued in MN
Legal business name
EAGLE TRACE WELLNESS CENTER, PA
Practice address
12002 County Road 11
Burnsville, MN 55337-3016
Phone
(952) 808-2922
Fax
(952) 808-2910
NPI assigned
Aug 26, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 26, 2008

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

Authorized official

Name
Dr. Elisa Marie Kensinger, D.C.NPI 1477723492
Title
Vice President, Secretary, Treasure
Phone
(952) 808-2922

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 3

Specialty (taxonomy)CodeLicenseStatePrimary
ChiropractorGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 111N00000X 5077 MN Primary
ChiropractorGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 111N00000X 5104 MN
AcupuncturistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 171100000X 832 MN

Addresses

Primary practice location

12002 County Road 11
Burnsville, MN 55337-3016

Mailing address

12002 County Road 11
Burnsville, MN 55337-3016
Phone (952) 808-2922

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080925000357 MN Part B Supplier - Clinic/Group Practice 7810064318 Receives reassigned benefits from 1 practitioner
Practice locations: Burnsville, MN

National Provider Directory

National Provider Directory

Locations

12002 County Road 11
Burnsville, MN 55337
Phone (952) 808-2922

Practitioners & affiliated clinicians

Practitioners 7

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

NPI Registry JSON

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

{
    "created_epoch": "1219708800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1219708800000",
    "number": "1790932390",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12002 COUNTY ROAD 11",
            "city": "BURNSVILLE",
            "state": "MN",
            "postal_code": "553373016",
            "telephone_number": "952-808-2922",
            "fax_number": "952-808-2910"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12002 COUNTY ROAD 11",
            "city": "BURNSVILLE",
            "state": "MN",
            "postal_code": "553373016",
            "telephone_number": "952-808-2922",
            "fax_number": "952-808-2910"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAGLE TRACE WELLNESS CENTER, PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-08-26",
        "last_updated": "2008-08-26",
        "status": "A",
        "authorized_official_last_name": "KENSINGER",
        "authorized_official_first_name": "ELISA",
        "authorized_official_middle_name": "MARIE",
        "authorized_official_title_or_position": "VICE PRESIDENT, SECRETARY, TREASURE",
        "authorized_official_telephone_number": "952-808-2922",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.C."
    },
    "taxonomies": [
        {
            "code": "111N00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Chiropractor",
            "state": "MN",
            "license": "5077",
            "primary": true
        },
        {
            "code": "111N00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Chiropractor",
            "state": "MN",
            "license": "5104",
            "primary": false
        },
        {
            "code": "171100000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Acupuncturist",
            "state": "MN",
            "license": "832",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Burnsville, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 26, 2008; 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.