Provider Demographics
NPI:1790843324
Name:GRANITE CITY CHIROPRACTIC, INC
Entity Type:Organization
Organization Name:GRANITE CITY CHIROPRACTIC, INC
Other - Org Name:NEW RICHLAND CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:W
Authorized Official - Last Name:MIELKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:507-463-3811
Mailing Address - Street 1:PO BOX 441
Mailing Address - Street 2:
Mailing Address - City:NEW RICHLAND
Mailing Address - State:MN
Mailing Address - Zip Code:56072-0441
Mailing Address - Country:US
Mailing Address - Phone:507-463-3811
Mailing Address - Fax:507-463-3812
Practice Address - Street 1:131 SOUTH BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW RICHLAND
Practice Address - State:MN
Practice Address - Zip Code:56072
Practice Address - Country:US
Practice Address - Phone:507-463-3811
Practice Address - Fax:507-463-3812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1496261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3KO36GROtherBLUE CROSS BLUE SHIELD