Healthcare Provider Details

I. General information

NPI: 1336101674
Provider Name (Legal Business Name): FREDERICK ASHLEY CLARY DC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1752 LEXINGTON AVE N
ROSEVILLE MN
55113-6516
US

IV. Provider business mailing address

1752 LEXINGTON AVE N
ROSEVILLE MN
55113-6516
US

V. Phone/Fax

Practice location:
  • Phone: 651-487-5950
  • Fax: 651-487-6016
Mailing address:
  • Phone: 651-487-5950
  • Fax: 651-487-6016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number2898
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: