Provider Demographics
NPI:1699854513
Name:LIESKE, BRUCE H (DC)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:H
Last Name:LIESKE
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 1:100 MAIN STREET SOUTH PO BOX 162
Mailing Address - Street 2:
Mailing Address - City:LONSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55046-0162
Mailing Address - Country:US
Mailing Address - Phone:507-744-5514
Mailing Address - Fax:507-744-5513
Practice Address - Street 1:100 MAIN STREET SOUTH
Practice Address - Street 2:
Practice Address - City:LONSDALE
Practice Address - State:MN
Practice Address - Zip Code:55046-0162
Practice Address - Country:US
Practice Address - Phone:507-744-5514
Practice Address - Fax:507-744-5513
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN003501111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN081322200Medicaid
MN350001590Medicare ID - Type Unspecified
MN081322200Medicaid