Healthcare Provider Details

I. General information

NPI: 1376455659
Provider Name (Legal Business Name): CONNOR RUSSELL BUMP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17205 ADELMANN ST SE
PRIOR LAKE MN
55372-3950
US

IV. Provider business mailing address

17205 ADELMANN ST SE
PRIOR LAKE MN
55372-3950
US

V. Phone/Fax

Practice location:
  • Phone: 612-868-2588
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number7364
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: