Provider Demographics
NPI:1790981538
Name:MICHAEL L. MARISTUEN D.C., P.A.
Entity Type:Organization
Organization Name:MICHAEL L. MARISTUEN D.C., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LAVERN
Authorized Official - Last Name:MARISTUEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-639-1066
Mailing Address - Street 1:2216 COUNTY ROAD D W
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55112-7500
Mailing Address - Country:US
Mailing Address - Phone:651-639-1066
Mailing Address - Fax:
Practice Address - Street 1:2216 COUNTY ROAD D W
Practice Address - Street 2:SUITE B
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55112-7500
Practice Address - Country:US
Practice Address - Phone:651-639-1066
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4409111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN318G5SPOtherBLUE CROSS BLUE SHIELD
MNC03495OtherNPPES
MNC03495OtherNPPES