Healthcare Provider Details

I. General information

NPI: 1124020896
Provider Name (Legal Business Name): RAYMOND W MIELKE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 BROADWAY AVE SO
NEW RICHLAND MN
56072
US

IV. Provider business mailing address

PO BOX 441
NEW RICHLAND MN
56072-0441
US

V. Phone/Fax

Practice location:
  • Phone: 507-463-3811
  • Fax: 507-463-3812
Mailing address:
  • Phone: 507-463-3811
  • Fax: 507-463-3812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number1496
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: