Provider Demographics
NPI:1548380355
Name:GRISE', DIANE MARIE (DC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:GRISE'
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2558 204TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:CEDAR
Mailing Address - State:MN
Mailing Address - Zip Code:55011-9395
Mailing Address - Country:US
Mailing Address - Phone:763-753-2857
Mailing Address - Fax:
Practice Address - Street 1:3158 VIKING BLVD NW
Practice Address - Street 2:
Practice Address - City:CEDAR
Practice Address - State:MN
Practice Address - Zip Code:55011-9339
Practice Address - Country:US
Practice Address - Phone:763-753-0993
Practice Address - Fax:763-753-0994
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2661111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4C419GROtherBLUECROSS BLUESHIELD
MN4C419GROtherBLUECROSS BLUESHIELD