Provider Demographics
NPI:1639117559
Name:FRID, LEON BORIS (DC)
Entity Type:Individual
Prefix:MR
First Name:LEON
Middle Name:BORIS
Last Name:FRID
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 1:4201 EXCELSIOR BLVD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4728
Mailing Address - Country:US
Mailing Address - Phone:952-933-8900
Mailing Address - Fax:952-945-9536
Practice Address - Street 1:3015 UTAH AVE S
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-3671
Practice Address - Country:US
Practice Address - Phone:952-933-1121
Practice Address - Fax:952-945-9536
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-03
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2008111NX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0100XChiropractic ProvidersChiropractorOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN506527500Medicaid