Healthcare Provider Details

I. General information

NPI: 1376528620
Provider Name (Legal Business Name): RANDY ROBERT CARLSON D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 08/29/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E LINCOLN AVE
FERGUS FALLS MN
56537-2238
US

IV. Provider business mailing address

301 E LINCOLN AVE
FERGUS FALLS MN
56537-2238
US

V. Phone/Fax

Practice location:
  • Phone: 218-736-3972
  • Fax: 218-736-7915
Mailing address:
  • Phone: 218-736-3972
  • Fax: 218-736-7915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number002984
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: