Provider Demographics
NPI:1407036627
Name:HALLGREN, STACY LANE (DC, CCEP, CST)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:LANE
Last Name:HALLGREN
Suffix:
Gender:F
Credentials:DC, CCEP, CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1772 22ND ST NE
Mailing Address - Street 2:
Mailing Address - City:EMERADO
Mailing Address - State:ND
Mailing Address - Zip Code:58228-9788
Mailing Address - Country:US
Mailing Address - Phone:701-594-8497
Mailing Address - Fax:
Practice Address - Street 1:4350 S WASHINGTON ST
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-7184
Practice Address - Country:US
Practice Address - Phone:701-732-2888
Practice Address - Fax:701-732-2711
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND798111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1407036627Medicaid
ND14609Medicaid
ND713023OtherPTAN
MN1407036627Medicaid