Healthcare Provider Details

I. General information

NPI: 1700882719
Provider Name (Legal Business Name): LYLE RICHARD ERICKSON D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 10/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 LAKE ST NW SUITE G,
WARROAD MN
56763-2116
US

IV. Provider business mailing address

PO BOX 930
WARROAD MN
56763-0930
US

V. Phone/Fax

Practice location:
  • Phone: 218-386-1930
  • Fax: 218-386-1921
Mailing address:
  • Phone: 218-386-1930
  • Fax: 218-386-1921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3705
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: