Provider Demographics
NPI:1043308992
Name:ORTH, HOLLY ELAINE (DC)
Entity Type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:ELAINE
Last Name:ORTH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 W DIVISION ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301
Mailing Address - Country:US
Mailing Address - Phone:320-529-9999
Mailing Address - Fax:
Practice Address - Street 1:3700 W DIVISION ST
Practice Address - Street 2:SUITE 101
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301
Practice Address - Country:US
Practice Address - Phone:320-529-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2169111N00000X
AZ4276111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN267527700Medicaid
00B250ROtherBCBS
T39484Medicare UPIN
MN267527700Medicaid