Provider Demographics
NPI:1396815718
Name:MICKELSON, THOMAS CARL (DC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:CARL
Last Name:MICKELSON
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 387
Mailing Address - Street 2:
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-0387
Mailing Address - Country:US
Mailing Address - Phone:218-681-4574
Mailing Address - Fax:218-681-4594
Practice Address - Street 1:1544 HWY 59 SE
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-2387
Practice Address - Country:US
Practice Address - Phone:218-681-4574
Practice Address - Fax:218-681-4594
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1695111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN705027500Medicaid
MN705027500Medicaid