Provider Demographics
NPI:1497741185
Name:COUILLARD, CRAIG ALAN (DC)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:ALAN
Last Name:COUILLARD
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 1:9202 202ND ST W
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-6855
Mailing Address - Country:US
Mailing Address - Phone:952-469-8385
Mailing Address - Fax:952-469-1713
Practice Address - Street 1:9202 202ND ST W
Practice Address - Street 2:SUITE 203
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-7915
Practice Address - Country:US
Practice Address - Phone:952-469-8385
Practice Address - Fax:952-469-1713
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3955111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN727678800Medicaid
MN350002308OtherMEDICAR PTAN
MN411991603OtherFEDERAL TAX ID #
MNU83802Medicare UPIN