Provider Demographics
NPI:1063530830
Name:MONGEON, GREGORY JOHN (DC)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:JOHN
Last Name:MONGEON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:GREGORY
Other - Middle Name:JOHN
Other - Last Name:MONGEON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:2855 S 70TH ST
Mailing Address - Street 2:STE 101
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-3700
Mailing Address - Country:US
Mailing Address - Phone:402-483-4300
Mailing Address - Fax:402-483-7789
Practice Address - Street 1:2855 S 70TH ST
Practice Address - Street 2:STE 101
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-3700
Practice Address - Country:US
Practice Address - Phone:402-483-4300
Practice Address - Fax:402-483-7789
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4427111N00000X
IL038011535111N00000X
NE1558111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN782696600Medicaid
NE10025835600Medicaid
NE10025835600Medicaid