Healthcare Provider Details

I. General information

NPI: 1699854513
Provider Name (Legal Business Name): BRUCE H LIESKE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 11/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MAIN STREET SOUTH
LONSDALE MN
55046-0162
US

IV. Provider business mailing address

100 MAIN STREET SOUTH PO BOX 162
LONSDALE MN
55046-0162
US

V. Phone/Fax

Practice location:
  • Phone: 507-744-5514
  • Fax: 507-744-5513
Mailing address:
  • Phone: 507-744-5514
  • Fax: 507-744-5513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number003501
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: