Provider Demographics
NPI:1447807813
Name:S GROUP PC
Entity type:Organization
Organization Name:S GROUP PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SKOG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-496-7871
Mailing Address - Street 1:4900 HIGHWAY 169 N STE 301
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55428-4019
Mailing Address - Country:US
Mailing Address - Phone:763-496-7871
Mailing Address - Fax:
Practice Address - Street 1:4900 HIGHWAY 169 N STE 301
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-4019
Practice Address - Country:US
Practice Address - Phone:763-496-7871
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-21
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty