Provider Demographics
NPI:1669366993
Name:MICK, JONATHAN
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:MICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6475 170TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROYALTON
Mailing Address - State:MN
Mailing Address - Zip Code:56373-3818
Mailing Address - Country:US
Mailing Address - Phone:320-431-4270
Mailing Address - Fax:
Practice Address - Street 1:6475 170TH AVE
Practice Address - Street 2:
Practice Address - City:ROYALTON
Practice Address - State:MN
Practice Address - Zip Code:56373-3818
Practice Address - Country:US
Practice Address - Phone:320-431-4270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-03
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372500000XNursing Service Related ProvidersChore ProviderGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment