Provider Demographics
NPI:1831102870
Name:MELLUM, NICHOLAS ANTHONY (DC)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:ANTHONY
Last Name:MELLUM
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 1:6640 LYNDALE AVE S
Mailing Address - Street 2:SUITE 120
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-2323
Mailing Address - Country:US
Mailing Address - Phone:612-866-1859
Mailing Address - Fax:612-866-2404
Practice Address - Street 1:6640 LYNDALE AVE S
Practice Address - Street 2:SUITE 120
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2323
Practice Address - Country:US
Practice Address - Phone:612-866-1859
Practice Address - Fax:612-866-2404
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4364111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN088L3ASOtherBCBS
MNU94577Medicare UPIN