Healthcare Provider Details

I. General information

NPI: 1558368209
Provider Name (Legal Business Name): SHAD LEROY SWANSON D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 AMERICA AVE NW
BEMIDJI MN
56601-3122
US

IV. Provider business mailing address

3807 VALLEY VIEW DR NE
BEMIDJI MN
56601-4754
US

V. Phone/Fax

Practice location:
  • Phone: 218-444-8727
  • Fax: 218-444-8546
Mailing address:
  • Phone: 218-751-2150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4040
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: