=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558719393
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOUNDATION INTERESTS GROUP, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2016
-----------------------------------------------------
Last Update Date | 07/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2001 2ND ST SW SUITE 125
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55902-4156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-320-1555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 835 40TH ST NW SUITE 217
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55901-4248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BRANDON MICKELSON
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 507-320-1555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 5904
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------