Provider Demographics
NPI:1104023860
Name:MITTENESS CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:MITTENESS CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:MITTENESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-563-4130
Mailing Address - Street 1:702 HIGHWAY 75 S
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:MN
Mailing Address - Zip Code:56296-9415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:702 HIGHWAY 75 S
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:MN
Practice Address - Zip Code:56296-9415
Practice Address - Country:US
Practice Address - Phone:320-563-4130
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1696111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3C935MIOtherBLUE CROSS BLUE SHIELD
MNC06563Medicare ID - Type UnspecifiedGROUP ID #