Healthcare Provider Details

I. General information

NPI: 1376511410
Provider Name (Legal Business Name): ERIC J KIESAU D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 MAIN ST, STE 1
LA CRESCENT MN
55947-1828
US

IV. Provider business mailing address

306 MAIN ST, STE 1
LA CRESCENT MN
55947-1828
US

V. Phone/Fax

Practice location:
  • Phone: 507-895-6015
  • Fax: 507-895-6345
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4226
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: