Provider Demographics
NPI:1083120372
Name:MOSENG CHIROPRACTIC PLLP
Entity Type:Organization
Organization Name:MOSENG CHIROPRACTIC PLLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:J
Authorized Official - Last Name:MADSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:320-269-7135
Mailing Address - Street 1:525 LEGION DR STE 1
Mailing Address - Street 2:
Mailing Address - City:MONTEVIDEO
Mailing Address - State:MN
Mailing Address - Zip Code:56265-1723
Mailing Address - Country:US
Mailing Address - Phone:320-269-7135
Mailing Address - Fax:320-269-7583
Practice Address - Street 1:525 LEGION DR STE 1
Practice Address - Street 2:
Practice Address - City:MONTEVIDEO
Practice Address - State:MN
Practice Address - Zip Code:56265-1723
Practice Address - Country:US
Practice Address - Phone:320-269-7135
Practice Address - Fax:320-269-7583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-21
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6138111N00000X
MN2209111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN647527200Medicaid