Healthcare Provider Details

I. General information

NPI: 1881853836
Provider Name (Legal Business Name): THERESA JOAN GROMALA DC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 06/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 W 89TH ST
BLOOMINGTON MN
55431-2007
US

IV. Provider business mailing address

2200 W 89TH ST
BLOOMINGTON MN
55431-2007
US

V. Phone/Fax

Practice location:
  • Phone: 612-599-9625
  • Fax:
Mailing address:
  • Phone: 612-599-9625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License Number2278
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code1744R1102X
TaxonomyResearch Study Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: