Healthcare Provider Details

I. General information

NPI: 1932275203
Provider Name (Legal Business Name): JERRY DEAN BLANCHARD CHIROPRACTOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 10/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 W 12TH STREET
GRAFTON ND
58237-0185
US

IV. Provider business mailing address

PO BOX 185
GRAFTON ND
58237-0185
US

V. Phone/Fax

Practice location:
  • Phone: 701-352-1690
  • Fax: 701-352-2258
Mailing address:
  • Phone: 701-352-1690
  • Fax: 701-352-2258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number311
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number1610
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: