=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134635485
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL ROBERT ALEXANDER DC, LN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2017
-----------------------------------------------------
Last Update Date | 10/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1700 S HWY 36 SERVICE DR #400
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55113-2453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-519-0552
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10725 202ND ST W
-----------------------------------------------------
City | LAKEVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55044-7861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-281-1240
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 6450
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number | N257
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------