Provider Demographics
NPI:1316489628
Name:KNUDSON, ERIC GREGORY (DC)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:GREGORY
Last Name:KNUDSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21897 S DIAMOND LAKE RD
Mailing Address - Street 2:STE 700
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-4642
Mailing Address - Country:US
Mailing Address - Phone:763-208-4424
Mailing Address - Fax:
Practice Address - Street 1:21897 S DIAMOND LAKE RD
Practice Address - Street 2:STE 700
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-4642
Practice Address - Country:US
Practice Address - Phone:763-208-4424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-17
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6248111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor