Provider Demographics
NPI:1235346784
Name:MARISTUEN, MICHAEL LAVERN (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LAVERN
Last Name:MARISTUEN
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 1:2216 COUNTY ROAD D W
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55112-7500
Mailing Address - Country:US
Mailing Address - Phone:651-639-1066
Mailing Address - Fax:651-639-1069
Practice Address - Street 1:2216 COUNTY ROAD D W
Practice Address - Street 2:SUITE B
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55112-7500
Practice Address - Country:US
Practice Address - Phone:651-639-1066
Practice Address - Fax:651-639-1069
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4409111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN318G5SPOtherBLUECROSS BLUESHIELD
MN318G5SPOtherBLUECROSS BLUESHIELD