Healthcare Provider Details

I. General information

NPI: 1043773013
Provider Name (Legal Business Name): JOHN MICHAEL KETELSEN DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1835 GATEWAY DR NW STE 104
COON RAPIDS MN
55448-4513
US

IV. Provider business mailing address

1835 GATEWAY DR NW STE 104
COON RAPIDS MN
55448-4513
US

V. Phone/Fax

Practice location:
  • Phone: 763-710-8888
  • Fax: 763-225-5629
Mailing address:
  • Phone: 763-710-8888
  • Fax: 763-225-5629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number6612
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: