Provider Demographics
NPI:1508063199
Name:WATERVILLE CHIROPRACTICE CENTER
Entity Type:Organization
Organization Name:WATERVILLE CHIROPRACTICE CENTER
Other - Org Name:MINNESOTA INSTITUTE OF WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MONGEON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:507-388-8883
Mailing Address - Street 1:1400 E MADISON AVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5473
Mailing Address - Country:US
Mailing Address - Phone:507-388-8883
Mailing Address - Fax:507-388-7620
Practice Address - Street 1:1400 E MADISON AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5473
Practice Address - Country:US
Practice Address - Phone:507-388-8883
Practice Address - Fax:507-388-7620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN496T8WAOtherBCBS
MNC03881Medicare ID - Type Unspecified