Provider Demographics
NPI:1326169772
Name:CARPENTER, BRIAN RICHARD
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:RICHARD
Last Name:CARPENTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7771 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-1100
Mailing Address - Country:US
Mailing Address - Phone:651-784-2225
Mailing Address - Fax:651-784-2070
Practice Address - Street 1:7771 LAKE DR
Practice Address - Street 2:
Practice Address - City:LINO LAKES
Practice Address - State:MN
Practice Address - Zip Code:55014-1100
Practice Address - Country:US
Practice Address - Phone:651-784-2225
Practice Address - Fax:651-784-2070
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3324111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN38-3661239OtherFEDERAL TAX ID #
MN377S4LAOtherBCBS CLINIC #
MNU62830Medicare UPIN