Provider Demographics
NPI:1164023735
Name:BOERM, MITCHELL LONNIE (DC)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:LONNIE
Last Name:BOERM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 G AVE
Mailing Address - Street 2:
Mailing Address - City:GRUNDY CENTER
Mailing Address - State:IA
Mailing Address - Zip Code:50638-1747
Mailing Address - Country:US
Mailing Address - Phone:319-824-3650
Mailing Address - Fax:
Practice Address - Street 1:412 G AVE
Practice Address - Street 2:
Practice Address - City:GRUNDY CENTER
Practice Address - State:IA
Practice Address - Zip Code:50638-1747
Practice Address - Country:US
Practice Address - Phone:319-824-3650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA105637111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor