Provider Demographics
NPI:1891729240
Name:MARTYELDRIDGE, SUSAN (DC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MARTYELDRIDGE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 EDEN AVE
Mailing Address - Street 2:STE 190
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55436-2316
Mailing Address - Country:US
Mailing Address - Phone:952-920-9721
Mailing Address - Fax:952-241-4355
Practice Address - Street 1:5201 EDEN AVE
Practice Address - Street 2:STE 190
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55436-2316
Practice Address - Country:US
Practice Address - Phone:952-920-9721
Practice Address - Fax:952-241-4355
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1566111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor