Provider Demographics
NPI:1760413363
Name:FORTHUN, PRESTON ELLARD (DC ATC)
Entity Type:Individual
Prefix:
First Name:PRESTON
Middle Name:ELLARD
Last Name:FORTHUN
Suffix:
Gender:M
Credentials:DC ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 2ND AVE NW
Mailing Address - Street 2:
Mailing Address - City:MILACA
Mailing Address - State:MN
Mailing Address - Zip Code:56353
Mailing Address - Country:US
Mailing Address - Phone:952-270-2150
Mailing Address - Fax:
Practice Address - Street 1:133 WEST LAKE STREET
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408
Practice Address - Country:US
Practice Address - Phone:612-823-2020
Practice Address - Fax:612-823-1919
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4690111N00000X
MN2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer