Provider Demographics
NPI:1740217694
Name:ERICKSON, KENT JAMES (DC)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:JAMES
Last Name:ERICKSON
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 1:5740 BROOKLYN BOULEVARD
Mailing Address - Street 2:100
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429
Mailing Address - Country:US
Mailing Address - Phone:763-561-4045
Mailing Address - Fax:763-561-8690
Practice Address - Street 1:5740 BROOKLYN BOULEVARD
Practice Address - Street 2:100
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429
Practice Address - Country:US
Practice Address - Phone:763-561-4045
Practice Address - Fax:763-561-8690
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1884111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN044727700Medicaid
T39754Medicare UPIN
MN044727700Medicaid