Provider Demographics
NPI:1619163227
Name:CARLSON, BENJAMIN JAMES (DC)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:JAMES
Last Name:CARLSON
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 1:4960 HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:MAPLE PLAIN
Mailing Address - State:MN
Mailing Address - Zip Code:55359
Mailing Address - Country:US
Mailing Address - Phone:763-479-3388
Mailing Address - Fax:763-479-3388
Practice Address - Street 1:4960 HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:MAPLE PLAIN
Practice Address - State:MN
Practice Address - Zip Code:55359-8729
Practice Address - Country:US
Practice Address - Phone:763-479-3388
Practice Address - Fax:763-479-3388
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN4108111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN350003384Medicare UPIN