Provider Demographics
NPI:1154034213
Name:MELLUM, BETHANIE ROUE (DC)
Entity type:Individual
Prefix:
First Name:BETHANIE
Middle Name:ROUE
Last Name:MELLUM
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15259 FLORIST CIR
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-4006
Mailing Address - Country:US
Mailing Address - Phone:651-274-8300
Mailing Address - Fax:
Practice Address - Street 1:101 LAKE ST W
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-1576
Practice Address - Country:US
Practice Address - Phone:952-473-1773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-03
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7036111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor