Provider Demographics
NPI:1578519310
Name:MITTENESS, PAUL M (DC)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:M
Last Name:MITTENESS
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 1:702 HIGHWAY 75 S
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:MN
Mailing Address - Zip Code:56296-9415
Mailing Address - Country:US
Mailing Address - Phone:320-563-4130
Mailing Address - Fax:320-563-8744
Practice Address - Street 1:702 HIGHWAY 75 S
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:MN
Practice Address - Zip Code:56296-9415
Practice Address - Country:US
Practice Address - Phone:320-563-4130
Practice Address - Fax:320-563-8744
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1696111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN607056OtherCHIRO CARE OF MN
MN3C936MIOtherBLUECROSS BLUESHIELD
MN782327400Medicaid
MN607056OtherCHIRO CARE OF MN