Healthcare Provider Details

I. General information

NPI: 1689694044
Provider Name (Legal Business Name): LANE N GUNNERSON DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 NW 4TH ST # 200
GRAND RAPIDS MN
55744-2209
US

IV. Provider business mailing address

1325 NW 4TH ST # 200
GRAND RAPIDS MN
55744-2209
US

V. Phone/Fax

Practice location:
  • Phone: 218-326-4022
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3335
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: