Provider Demographics
NPI:1528390564
Name:GREGORY J. MONGEON, DC, PC
Entity Type:Organization
Organization Name:GREGORY J. MONGEON, DC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
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:612-499-1008
Mailing Address - Street 1:2508 BORDEAUX LN APT 208
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-2013
Mailing Address - Country:US
Mailing Address - Phone:612-499-1008
Mailing Address - Fax:
Practice Address - Street 1:2855 S 70TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-3700
Practice Address - Country:US
Practice Address - Phone:612-499-1008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1558111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN782696600Medicaid
MN782696600Medicaid