Provider Demographics
NPI:1144281643
Name:EDWARDS, BRYAN W (DC)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:W
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8909 PORTLAND AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-2918
Mailing Address - Country:US
Mailing Address - Phone:952-887-1687
Mailing Address - Fax:
Practice Address - Street 1:2172 SILVER LAKE RD NW
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-5302
Practice Address - Country:US
Practice Address - Phone:651-633-8110
Practice Address - Fax:651-633-2831
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4172111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN292R6EDOtherBCBS