Healthcare Provider Details

I. General information

NPI: 1073671764
Provider Name (Legal Business Name): PAUL WILLIAM BENDER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 GRAYSTONE PLZ SUITE 110
DETROIT LAKES MN
56501-3034
US

IV. Provider business mailing address

119 GRAYSTONE PLZ SUITE 110
DETROIT LAKES MN
56501-3034
US

V. Phone/Fax

Practice location:
  • Phone: 218-847-2631
  • Fax: 218-847-0048
Mailing address:
  • Phone: 218-847-2631
  • Fax: 218-847-0048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4590
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: