Provider Demographics
NPI:1508333527
Name:PEDERSON, MARSHAL H (DC)
Entity Type:Individual
Prefix:DR
First Name:MARSHAL
Middle Name:H
Last Name:PEDERSON
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 1:2840 19TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-5957
Mailing Address - Country:US
Mailing Address - Phone:701-772-2670
Mailing Address - Fax:701-772-2706
Practice Address - Street 1:2840 19TH AVE S
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-5957
Practice Address - Country:US
Practice Address - Phone:701-772-2670
Practice Address - Fax:701-772-2706
Is Sole Proprietor?:No
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1092111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1092OtherND BOARD OF CHIROPRACTIC EXAMINERS