Provider Demographics
NPI:1922143726
Name:CARROLL, BRUCE CHARLES (DC)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:CHARLES
Last Name:CARROLL
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 1:9 3RD ST NE
Mailing Address - Street 2:
Mailing Address - City:AITKIN
Mailing Address - State:MN
Mailing Address - Zip Code:56431-1421
Mailing Address - Country:US
Mailing Address - Phone:218-927-2541
Mailing Address - Fax:
Practice Address - Street 1:9 3RD ST NE
Practice Address - Street 2:
Practice Address - City:AITKIN
Practice Address - State:MN
Practice Address - Zip Code:56431-1421
Practice Address - Country:US
Practice Address - Phone:218-927-2541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1720111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN41M15CAOtherBLUE CROSS PROVIDER PIN
MNP00130495OtherRAILROAD MEDICARE PIN