Healthcare Provider Details

I. General information

NPI: 1306043997
Provider Name (Legal Business Name): MINNESOTA INSTITUTE OF WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 08/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 LONDON RD
DULUTH MN
55812-1617
US

IV. Provider business mailing address

1525 LONDON RD
DULUTH MN
55812-1617
US

V. Phone/Fax

Practice location:
  • Phone: 218-722-4845
  • Fax: 218-722-8480
Mailing address:
  • Phone: 218-722-4845
  • Fax: 218-722-8480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: GREGORY MONGEON
Title or Position: OWNER
Credential: D.C.
Phone: 218-722-4845