Provider Demographics
NPI:1790975324
Name:MICK, TIMOTHY JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JOHN
Last Name:MICK
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 1:565 ARLINGTON AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-3504
Mailing Address - Country:US
Mailing Address - Phone:651-487-2429
Mailing Address - Fax:
Practice Address - Street 1:565 ARLINGTON AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55117-3504
Practice Address - Country:US
Practice Address - Phone:651-487-2429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2731111NR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0200XChiropractic ProvidersChiropractorRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU30633Medicare UPIN