Healthcare Provider Details

I. General information

NPI: 1639444300
Provider Name (Legal Business Name): STUART CHARLES LAMP D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2012
Last Update Date: 04/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4554 38TH AVE S STE E
FARGO ND
58104-8515
US

IV. Provider business mailing address

4554 38TH AVE S STE E
FARGO ND
58104-8515
US

V. Phone/Fax

Practice location:
  • Phone: 701-277-3081
  • Fax: 701-277-3052
Mailing address:
  • Phone: 701-277-3081
  • Fax: 701-277-3052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number907
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: