Provider Demographics
NPI:1457595886
Name:VAN BOGART, DESIREE MARCELINE (DC)
Entity Type:Individual
Prefix:DR
First Name:DESIREE
Middle Name:MARCELINE
Last Name:VAN BOGART
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 W. MAIN STREET
Mailing Address - Street 2:SUITE 10
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303
Mailing Address - Country:US
Mailing Address - Phone:612-968-3385
Mailing Address - Fax:
Practice Address - Street 1:530 W MAIN ST
Practice Address - Street 2:SUITE 10
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-2063
Practice Address - Country:US
Practice Address - Phone:612-968-3385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-29
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5197111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor