Provider Demographics
NPI:1326268392
Name:OMDAHL, ERIC (DC)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:
Last Name:OMDAHL
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 1:213 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MN
Mailing Address - Zip Code:55972-1403
Mailing Address - Country:US
Mailing Address - Phone:507-932-5696
Mailing Address - Fax:
Practice Address - Street 1:213 E 6TH ST
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MN
Practice Address - Zip Code:55972-1403
Practice Address - Country:US
Practice Address - Phone:507-932-5696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4958111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN123D50MOtherBLUE CROSS BLUE SHIELD MN