Provider Demographics
NPI:1427171636
Name:VALLEY SPINE CENTER, INC.
Entity type:Organization
Organization Name:VALLEY SPINE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALISA
Authorized Official - Middle Name:T
Authorized Official - Last Name:MITSKOG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-642-6480
Mailing Address - Street 1:PO BOX 561
Mailing Address - Street 2:
Mailing Address - City:WAHPETON
Mailing Address - State:ND
Mailing Address - Zip Code:58074-0561
Mailing Address - Country:US
Mailing Address - Phone:701-642-6480
Mailing Address - Fax:701-642-6011
Practice Address - Street 1:319 11TH ST N
Practice Address - Street 2:
Practice Address - City:WAHPETON
Practice Address - State:ND
Practice Address - Zip Code:58075-4111
Practice Address - Country:US
Practice Address - Phone:701-642-6480
Practice Address - Fax:701-642-6011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND289111N00000X
ND750111N00000X
ND500111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND24675OtherBCBS
MN922509900Medicaid
ND25401OtherBCBS DR. ROBB DOHMAN
ND17175Medicaid
ND296001OtherBCBS WAHPETON
ND634001OtherBCBS LIDGERWOOD
MN91002MIOtherBCBS
ND13184Medicaid
ND13349Medicaid
MN16659600Medicaid
MN71653MIOtherBCBS
ND25402OtherBCBS DR. ALISA MITSKOG
MN500688100Medicaid
MN16659600Medicaid
N711335Medicare ID - Type Unspecified
MN500688100Medicaid
ND296001OtherBCBS WAHPETON
MN71653MIOtherBCBS
ND13184Medicaid
ND13349Medicaid