Provider Demographics
NPI:1003056961
Name:MIEDEMA, MANDI LYNNE (DC)
Entity Type:Individual
Prefix:DR
First Name:MANDI
Middle Name:LYNNE
Last Name:MIEDEMA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11605 MERIDIAN MARKET VW STE 142
Mailing Address - Street 2:
Mailing Address - City:FALCON
Mailing Address - State:CO
Mailing Address - Zip Code:80831-8238
Mailing Address - Country:US
Mailing Address - Phone:701-830-0431
Mailing Address - Fax:
Practice Address - Street 1:11605 MERIDIAN MARKET VW STE 142
Practice Address - Street 2:
Practice Address - City:FALCON
Practice Address - State:CO
Practice Address - Zip Code:80831-8238
Practice Address - Country:US
Practice Address - Phone:701-830-0431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-04
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6600111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor