Basic Information
Provider Information | |||||||||
NPI: | 1316022445 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MADISON CHIROPRACTIC CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 508 W 4TH ST | ||||||||
Address2: |   | ||||||||
City: | MADISON | ||||||||
State: | MN | ||||||||
PostalCode: | 562561426 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3205983089 | ||||||||
FaxNumber: | 3205983211 | ||||||||
Practice Location | |||||||||
Address1: | 508 W 4TH ST | ||||||||
Address2: |   | ||||||||
City: | MADISON | ||||||||
State: | MN | ||||||||
PostalCode: | 562561426 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3205983089 | ||||||||
FaxNumber: | 3205983211 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/26/2006 | ||||||||
LastUpdateDate: | 11/18/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BONN | ||||||||
AuthorizedOfficialFirstName: | CLINTON | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 3205983089 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.C. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 3882 | MN | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |   |
ID Information
ID | Type | State | Issuer | Description | 721157100 | 05 | MN |   | MEDICAID | 54B82MA | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER |