Healthcare Provider Details

I. General information

NPI: 1619163227
Provider Name (Legal Business Name): BENJAMIN JAMES CARLSON D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2007
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4960 HIGHWAY 12
MAPLE PLAIN MN
55359-8729
US

IV. Provider business mailing address

4960 HIGHWAY 12
MAPLE PLAIN MN
55359
US

V. Phone/Fax

Practice location:
  • Phone: 763-479-3388
  • Fax: 763-479-3388
Mailing address:
  • Phone: 763-479-3388
  • Fax: 763-479-3388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberMN4108
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: