Provider Demographics
NPI:1558542530
Name:MINTELL, KIMBERLEY M (DC)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:M
Last Name:MINTELL
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:PO BOX 177
Mailing Address - Street 2:
Mailing Address - City:LINDSTROM
Mailing Address - State:MN
Mailing Address - Zip Code:55045-0177
Mailing Address - Country:US
Mailing Address - Phone:612-801-1099
Mailing Address - Fax:612-677-3501
Practice Address - Street 1:4635 WHITE BEAR PKWY
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3300
Practice Address - Country:US
Practice Address - Phone:612-801-1099
Practice Address - Fax:612-677-3501
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3423111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN350002146Medicare UPIN