Provider Demographics
NPI:1669846689
Name:MADSEN, BROCK (DC)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:
Last Name:MADSEN
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 1:525 LEGION DR
Mailing Address - Street 2:STE #1
Mailing Address - City:MONTEVIDEO
Mailing Address - State:MN
Mailing Address - Zip Code:56265-1722
Mailing Address - Country:US
Mailing Address - Phone:320-269-7135
Mailing Address - Fax:320-269-7583
Practice Address - Street 1:525 LEGION DR
Practice Address - Street 2:STE #1
Practice Address - City:MONTEVIDEO
Practice Address - State:MN
Practice Address - Zip Code:56265-1722
Practice Address - Country:US
Practice Address - Phone:320-269-7135
Practice Address - Fax:320-269-7583
Is Sole Proprietor?:No
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6138111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor