Provider Demographics
NPI:1659377232
Name:GODFREY, MARC HOWARD (DC)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:HOWARD
Last Name:GODFREY
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 1:119 6TH AVE E
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-1801
Mailing Address - Country:US
Mailing Address - Phone:320-762-8185
Mailing Address - Fax:320-762-8186
Practice Address - Street 1:119 6TH AVE E
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-1801
Practice Address - Country:US
Practice Address - Phone:320-762-8185
Practice Address - Fax:320-762-8186
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1436111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN499325000Medicaid
MN230281OtherCCMI
MN61452GOOtherBCBS
MN499325000Medicaid
MN61452GOOtherBCBS