Healthcare Provider Details

I. General information

NPI: 1407036627
Provider Name (Legal Business Name): STACY LANE HALLGREN D.C., C.C.E.P., CST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2007
Last Update Date: 08/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 S WASHINGTON ST SUITE 100
GRAND FORKS ND
58201-7184
US

IV. Provider business mailing address

1772 22ND ST NE
EMERADO ND
58228-9788
US

V. Phone/Fax

Practice location:
  • Phone: 701-732-2888
  • Fax: 701-732-2711
Mailing address:
  • Phone: 701-594-8497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number798
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: