Provider Demographics
NPI:1346280781
Name:AMELI, MAHMOOD (DC DACAN)
Entity Type:Individual
Prefix:MR
First Name:MAHMOOD
Middle Name:
Last Name:AMELI
Suffix:
Gender:M
Credentials:DC DACAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16372 KENRICK AVENUE
Mailing Address - Street 2:SUITE 100 LAKEVILLE INTEGRATIVE MEDICINE CLINIC
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044
Mailing Address - Country:US
Mailing Address - Phone:952-892-6700
Mailing Address - Fax:952-892-9475
Practice Address - Street 1:16372 KENRICK AVENUE
Practice Address - Street 2:SUITE 100 LAKEVILLE INTEGRATIVE MEDICINE CLINIC
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044
Practice Address - Country:US
Practice Address - Phone:952-892-6700
Practice Address - Fax:952-892-9475
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1237111N00000X
MN153111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4401618OtherMEDICA PROVIDER NUMBER
MN127725100Medicaid
MN127725100Medicaid