Provider Demographics
NPI:1801120258
Name:MADISON CHIROPRACTIC CENTER PC
Entity type:Organization
Organization Name:MADISON CHIROPRACTIC CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:A
Authorized Official - Last Name:BONN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:320-598-3089
Mailing Address - Street 1:508 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MN
Mailing Address - Zip Code:56256
Mailing Address - Country:US
Mailing Address - Phone:218-312-3002
Mailing Address - Fax:218-312-3003
Practice Address - Street 1:508 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MN
Practice Address - Zip Code:56256-1426
Practice Address - Country:US
Practice Address - Phone:320-598-3089
Practice Address - Fax:320-598-3211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-01
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3882261QP3300X, 261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3BW40MAOtherBLUE CROSS BLUE SHIELD
MN721157100Medicaid
MNC05424Medicare PIN