Healthcare Provider Details

I. General information

NPI: 1003686445
Provider Name (Legal Business Name): ROOSEVELT YANG DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2024
Last Update Date: 01/08/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 LEXINGTON AVE N
SAINT PAUL MN
55113-4313
US

IV. Provider business mailing address

2201 LEXINGTON AVE N
SAINT PAUL MN
55113-4313
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number7183
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: