Provider Demographics
NPI:1932665965
Name:VIDMAR, MIA MARIE (MCM, LAC, DIPLAC)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:MARIE
Last Name:VIDMAR
Suffix:
Gender:F
Credentials:MCM, LAC, DIPLAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 PRAIRIE CENTER DR STE 210
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-7328
Mailing Address - Country:US
Mailing Address - Phone:952-234-9210
Mailing Address - Fax:
Practice Address - Street 1:800 PRAIRIE CENTER DR STE 210
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-7328
Practice Address - Country:US
Practice Address - Phone:952-234-9210
Practice Address - Fax:952-204-3933
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1902171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist