Provider Demographics
NPI:1538218284
Name:MAHTOMEDI NATURAL CARE CENTER
Entity type:Organization
Organization Name:MAHTOMEDI NATURAL CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR. GINA FIALA
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-407-0802
Mailing Address - Street 1:1526 MAHTOMEDI AVE
Mailing Address - Street 2:
Mailing Address - City:MAHTOMEDI
Mailing Address - State:MN
Mailing Address - Zip Code:55115
Mailing Address - Country:US
Mailing Address - Phone:651-407-0802
Mailing Address - Fax:651-407-0812
Practice Address - Street 1:1526 MAHTOMEDI AVE
Practice Address - Street 2:
Practice Address - City:MAHTOMEDI
Practice Address - State:MN
Practice Address - Zip Code:55115
Practice Address - Country:US
Practice Address - Phone:651-407-0802
Practice Address - Fax:651-407-0812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X
MNMN4887111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN996697000Medicaid
MN996697000Medicaid