Provider Demographics
NPI:1851789341
Name:BETZOLD, THAD CHRISTOPHER (DC)
Entity Type:Individual
Prefix:DR
First Name:THAD
Middle Name:CHRISTOPHER
Last Name:BETZOLD
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 1:8519 EAGLE POINT BLVD
Mailing Address - Street 2:SUITE 175
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-8629
Mailing Address - Country:US
Mailing Address - Phone:651-207-4411
Mailing Address - Fax:651-348-6462
Practice Address - Street 1:8519 EAGLE POINT BLVD
Practice Address - Street 2:SUITE 175
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-8629
Practice Address - Country:US
Practice Address - Phone:651-207-4411
Practice Address - Fax:651-348-6462
Is Sole Proprietor?:No
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6027111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor