Provider Demographics
NPI:1720090814
Name:KENT J. ERICKSON, D.C., CHTD
Entity type:Organization
Organization Name:KENT J. ERICKSON, D.C., CHTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:J
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-561-4045
Mailing Address - Street 1:5740 BROOKLYN BLVD
Mailing Address - Street 2:#100
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429
Mailing Address - Country:US
Mailing Address - Phone:763-561-4045
Mailing Address - Fax:763-561-8690
Practice Address - Street 1:5740 BROOKLYN BLVD
Practice Address - Street 2:#100
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429
Practice Address - Country:US
Practice Address - Phone:763-561-4045
Practice Address - Fax:763-561-8690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN044727700Medicaid