MEDICARE: DR. MITCHEL VINCENT MONDO D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	1928	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	274827400	OTHER	MN	MEDICAL ASSISTANCE

General Provider Information

NPI Number	:	1730289885
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MITCHEL VINCENT MONDO D.C.

Provider Business Mailing Address
First Line	:	1310 HIGHWAY 96 E
Second Line	:	SUITE # 206
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-3624
Country	:	US
Telephone Number	:	651-429-0101
Fax Number	:	651-407-3163

Provider Business Practice Location Address
First Line	:	1310 HIGHWAY 96 E
Second Line	:	SUITE # 206
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-3624
Country	:	US
Telephone Number	:	651-429-0101
Fax Number	:	651-407-3163

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	07/08/2007

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