Healthcare Provider Details

I. General information

NPI: 1801120258
Provider Name (Legal Business Name): MADISON CHIROPRACTIC CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2009
Last Update Date: 01/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 W 4TH ST
MADISON MN
56256-1426
US

IV. Provider business mailing address

508 W 4TH ST
MADISON MN
56256
US

V. Phone/Fax

Practice location:
  • Phone: 320-598-3089
  • Fax: 320-598-3211
Mailing address:
  • Phone: 218-312-3002
  • Fax: 218-312-3003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number3882
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number3882
License Number StateMN

VIII. Authorized Official

Name: CLINTON A BONN
Title or Position: OWNER
Credential: DC
Phone: 320-598-3089