Provider Demographics
NPI:1699045336
Name:STODOLA, MACKENZIE JO (DC)
Entity Type:Individual
Prefix:DR
First Name:MACKENZIE
Middle Name:JO
Last Name:STODOLA
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 1:14020 HWY 13 S STE 650
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-7106
Mailing Address - Country:US
Mailing Address - Phone:952-447-8980
Mailing Address - Fax:952-447-8941
Practice Address - Street 1:14020 HWY 13 S
Practice Address - Street 2:650
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-7100
Practice Address - Country:US
Practice Address - Phone:952-447-8980
Practice Address - Fax:952-447-8941
Is Sole Proprietor?:No
Enumeration Date:2012-01-11
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5590111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor