Provider Demographics
NPI:1164512646
Name:REDEBAUGH, JOHN CHARLES (DC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES
Last Name:REDEBAUGH
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:PO BOX 689
Mailing Address - Street 2:
Mailing Address - City:NISSWA
Mailing Address - State:MN
Mailing Address - Zip Code:56468-0689
Mailing Address - Country:US
Mailing Address - Phone:218-963-2944
Mailing Address - Fax:218-963-0899
Practice Address - Street 1:5314 NISSWA AVE
Practice Address - Street 2:
Practice Address - City:NISSWA
Practice Address - State:MN
Practice Address - Zip Code:56474
Practice Address - Country:US
Practice Address - Phone:218-963-2944
Practice Address - Fax:219-963-0899
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1512111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNT66040Medicare UPIN