Provider Demographics
NPI:1447476734
Name:ST CLOUD CHIROPRACTIC
Entity type:Organization
Organization Name:ST CLOUD CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:WOGGON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:320-252-5599
Mailing Address - Street 1:437 33RD AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4846
Mailing Address - Country:US
Mailing Address - Phone:320-252-5599
Mailing Address - Fax:320-253-4585
Practice Address - Street 1:437 33RD AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4846
Practice Address - Country:US
Practice Address - Phone:320-252-5599
Practice Address - Fax:320-253-4585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1313111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN55417CLOtherBLUE CROSS
MNC07645Medicare ID - Type Unspecified