Provider Demographics
NPI:1316149297
Name:MATTSON, ROBERT (DC CCSP)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:MATTSON
Suffix:
Gender:M
Credentials:DC CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 E CHAPMAN ST
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:MN
Mailing Address - Zip Code:55731-1428
Mailing Address - Country:US
Mailing Address - Phone:218-365-4111
Mailing Address - Fax:
Practice Address - Street 1:247 E CHAPMAN ST
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:MN
Practice Address - Zip Code:55731-1428
Practice Address - Country:US
Practice Address - Phone:218-365-4111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2841111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU20587Medicare UPIN