Healthcare Provider Details

I. General information

NPI: 1588600043
Provider Name (Legal Business Name): IHS MIDWEST PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 HIGHWAY 25 S
MONTICELLO MN
55362-9306
US

IV. Provider business mailing address

450 FORD RD UNIT 101
ST LOUIS PARK MN
55426-1058
US

V. Phone/Fax

Practice location:
  • Phone: 651-334-1290
  • Fax: 763-295-9116
Mailing address:
  • Phone: 651-334-1290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. CHRISTOPHER PAUL MASSOGLIA SR.
Title or Position: PRESIDENT
Credential: DC
Phone: 651-334-1290