Healthcare Provider Details

I. General information

NPI: 1376635755
Provider Name (Legal Business Name): SCOTT EDWARD OMDALEN DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 1ST AVE SE
MAYVILLE ND
58257
US

IV. Provider business mailing address

45 1ST AVE SE
MAYVILLE ND
58257
US

V. Phone/Fax

Practice location:
  • Phone: 701-786-4024
  • Fax: 701-786-4034
Mailing address:
  • Phone: 701-786-4024
  • Fax: 701-786-4034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number486
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: