Healthcare Provider Details

I. General information

NPI: 1487089165
Provider Name (Legal Business Name): MOLLY LANE BIRD D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2013
Last Update Date: 03/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1053 GRAND AVE STE 114
SAINT PAUL MN
55105-3074
US

IV. Provider business mailing address

12770 GERMANE AVE APT 303
APPLE VALLEY MN
55124-6794
US

V. Phone/Fax

Practice location:
  • Phone: 651-292-9247
  • Fax: 651-348-6367
Mailing address:
  • Phone: 314-580-8424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5839
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: