Provider Demographics
NPI:1093881989
Name:BERRY, MARY C (DC)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:C
Last Name:BERRY
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:PO BOX 95
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371-0095
Mailing Address - Country:US
Mailing Address - Phone:763-631-3070
Mailing Address - Fax:
Practice Address - Street 1:31835 124TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-3316
Practice Address - Country:US
Practice Address - Phone:763-631-3070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4094111N00000X
TX8666111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN520082200Medicaid
TX609963Medicare ID - Type Unspecified
MN520082200Medicaid
U97168Medicare UPIN