Provider Demographics
NPI:1366600629
Name:MEDELBERG FAMILY CHIROPRACTIC, P.A.
Entity type:Organization
Organization Name:MEDELBERG FAMILY CHIROPRACTIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MEDELBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:320-271-1800
Mailing Address - Street 1:710 COUNTY ROAD 75
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MN
Mailing Address - Zip Code:56374-8648
Mailing Address - Country:US
Mailing Address - Phone:320-271-1800
Mailing Address - Fax:320-271-1808
Practice Address - Street 1:710 COUNTY ROAD 75
Practice Address - Street 2:SUITE 103
Practice Address - City:SAINT JOSEPH
Practice Address - State:MN
Practice Address - Zip Code:56374-8648
Practice Address - Country:US
Practice Address - Phone:320-271-1800
Practice Address - Fax:320-271-1808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3062111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN309313100Medicaid
MN350003218Medicare PIN