Healthcare Provider Details

I. General information

NPI: 1669866968
Provider Name (Legal Business Name): TARA CARLSON D.C,
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2015
Last Update Date: 03/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 TWELVE OAKS CENTER DR SUITE 734
WAYZATA MN
55391-4401
US

IV. Provider business mailing address

572 HARRINGTON RD
WAYZATA MN
55391-1550
US

V. Phone/Fax

Practice location:
  • Phone: 952-215-9411
  • Fax:
Mailing address:
  • Phone: 952-215-9411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NP0017X
TaxonomyPediatric Chiropractor
License Number6055
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: