Provider Demographics
NPI:1649555715
Name:MYSTICAL ROSE CHIROPRACTIC LLC
Entity type:Organization
Organization Name:MYSTICAL ROSE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:WANJIRU
Authorized Official - Last Name:NJOGU
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:612-310-8662
Mailing Address - Street 1:8200 HUMBOLDT AVE S
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-1433
Mailing Address - Country:US
Mailing Address - Phone:952-884-6144
Mailing Address - Fax:952-884-9180
Practice Address - Street 1:8200 HUMBOLDT AVE S
Practice Address - Street 2:SUITE 204
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-1433
Practice Address - Country:US
Practice Address - Phone:952-884-6144
Practice Address - Fax:952-884-9180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-20
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1094302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC05946OtherMEDICARE PTAN NUMBER