Provider Demographics
NPI:1306043997
Name:MINNESOTA INSTITUTE OF WELLNESS
Entity Type:Organization
Organization Name:MINNESOTA INSTITUTE OF WELLNESS
Other - Org Name:INSTITUTE FOR WHOLE HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:MONGEON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-722-4845
Mailing Address - Street 1:1525 LONDON RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55812-1617
Mailing Address - Country:US
Mailing Address - Phone:218-722-4845
Mailing Address - Fax:218-722-8480
Practice Address - Street 1:1525 LONDON RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55812-1617
Practice Address - Country:US
Practice Address - Phone:218-722-4845
Practice Address - Fax:218-722-8480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN015855100Medicaid
MN496T8WAOtherBCBS
MN050G7WAOtherBCBS
MNC03881Medicare ID - Type Unspecified