Healthcare Provider Details

I. General information

NPI: 1043831225
Provider Name (Legal Business Name): MATTHEW VRADENBURG DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2020
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11500 WAYZATA BLVD PMB 1025
MINNETONKA MN
55305
US

IV. Provider business mailing address

6300 VIRGINIA AVE N
BROOKLYN PARK MN
55428-2162
US

V. Phone/Fax

Practice location:
  • Phone: 763-260-1469
  • Fax:
Mailing address:
  • Phone: 763-267-1455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number11698237-8007
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number7187
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: