Provider Demographics
NPI:1265520274
Name:HAGSTROM, STEVEN (DC)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:HAGSTROM
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 1:814 MAHTOMEDI AVE
Mailing Address - Street 2:
Mailing Address - City:MAHTOMEDI
Mailing Address - State:MN
Mailing Address - Zip Code:55115-1730
Mailing Address - Country:US
Mailing Address - Phone:651-426-2210
Mailing Address - Fax:651-426-2210
Practice Address - Street 1:814 MAHTOMEDI AVE
Practice Address - Street 2:
Practice Address - City:MAHTOMEDI
Practice Address - State:MN
Practice Address - Zip Code:55115-1730
Practice Address - Country:US
Practice Address - Phone:651-426-2210
Practice Address - Fax:651-426-2210
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2952111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN698528900Medicaid
MN698528900Medicaid
MN350002523Medicare PIN