Provider Demographics
NPI:1891805172
Name:ANDERSON, MYREN DEAN (DC)
Entity Type:Individual
Prefix:
First Name:MYREN
Middle Name:DEAN
Last Name:ANDERSON
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:PO BOX 327
Mailing Address - Street 2:121 3RD STREET
Mailing Address - City:STEPHEN
Mailing Address - State:MN
Mailing Address - Zip Code:56757
Mailing Address - Country:US
Mailing Address - Phone:218-478-2415
Mailing Address - Fax:218-478-3083
Practice Address - Street 1:121 3RD STREET
Practice Address - Street 2:
Practice Address - City:STEPHEN
Practice Address - State:MN
Practice Address - Zip Code:56757
Practice Address - Country:US
Practice Address - Phone:218-478-2415
Practice Address - Fax:218-478-3083
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1164111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNMN86627ANOtherBCBS
MNMA905525800Medicaid
791350940OtherRAILROAD MEDICARE
NDND4385OtherBCBS