Provider Demographics
NPI:1316058605
Name:DETLEFSEN, PHILLIP JOHN (DC)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:JOHN
Last Name:DETLEFSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13601 80TH CIR N
Mailing Address - Street 2:SUITE L70
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-8999
Mailing Address - Country:US
Mailing Address - Phone:763-420-4635
Mailing Address - Fax:763-390-1381
Practice Address - Street 1:13601 80TH CIR N
Practice Address - Street 2:SUITE L70
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-8999
Practice Address - Country:US
Practice Address - Phone:763-420-4635
Practice Address - Fax:763-390-1381
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4374111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN350002914Medicare ID - Type Unspecified
MNU95882Medicare UPIN