Provider Demographics
NPI:1629140181
Name:BOLLINGBERG, FAYE E (DC)
Entity Type:Individual
Prefix:DR
First Name:FAYE
Middle Name:E
Last Name:BOLLINGBERG
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 W OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-2318
Mailing Address - Country:US
Mailing Address - Phone:507-433-4013
Mailing Address - Fax:507-433-4026
Practice Address - Street 1:704 W OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-2318
Practice Address - Country:US
Practice Address - Phone:507-433-4013
Practice Address - Fax:507-433-4026
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN02933111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN61D11BOOtherINDIVIDUAL BCBS
MN224817400Medicaid
MN224817400Medicaid
MN61D11BOOtherINDIVIDUAL BCBS