Provider Demographics
NPI:1922148774
Name:DEROSIER CHIROPRACTIC CLINIC, P.C.
Entity Type:Organization
Organization Name:DEROSIER CHIROPRACTIC CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:R
Authorized Official - Last Name:DEROSIER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-284-6040
Mailing Address - Street 1:4005 OVERLOOK DR
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-8216
Mailing Address - Country:US
Mailing Address - Phone:701-866-4084
Mailing Address - Fax:
Practice Address - Street 1:4005 OVERLOOK DR
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-8216
Practice Address - Country:US
Practice Address - Phone:701-866-4084
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2007-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN517261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU89934Medicare UPIN