Basic Information
| Provider Information | |||||||||
| NPI: | 1801120258 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MADISON CHIROPRACTIC CENTER PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 508 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183123002 | ||||||||
| FaxNumber: | 2183123003 | ||||||||
| Practice Location | |||||||||
| Address1: | 508 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562561426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205983089 | ||||||||
| FaxNumber: | 3205983211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2009 | ||||||||
| LastUpdateDate: | 01/13/2010 | ||||||||
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| AuthorizedOfficialLastName: | BONN | ||||||||
| AuthorizedOfficialFirstName: | CLINTON | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3205983089 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | 3882 | MN | N | Ambulatory Health Care Facilities | Clinic/Center | Pain | 261QH0100X | 3882 | MN | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
ID Information
| ID | Type | State | Issuer | Description | 3BW40MA | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | 721157100 | 05 | MN | MEDICAID |