Provider Demographics
NPI:1871530352
Name:BEAR TOWN CHIROPRACTIC CLINIC, P.A.
Entity type:Organization
Organization Name:BEAR TOWN CHIROPRACTIC CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:HEURUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-429-1447
Mailing Address - Street 1:2186 3RD ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3263
Mailing Address - Country:US
Mailing Address - Phone:651-429-1447
Mailing Address - Fax:651-429-5008
Practice Address - Street 1:2186 3RD ST
Practice Address - Street 2:SUITE 104
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3263
Practice Address - Country:US
Practice Address - Phone:651-429-1447
Practice Address - Fax:651-429-5008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3282111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty