Provider Demographics
NPI:1972679777
Name:KULLBERG, WILLIAM GEORGE (DC)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:GEORGE
Last Name:KULLBERG
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 1:606 8TH AVE
Mailing Address - Street 2:P.O. BOX 548
Mailing Address - City:HOWARD LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55349
Mailing Address - Country:US
Mailing Address - Phone:320-543-2345
Mailing Address - Fax:
Practice Address - Street 1:606 EIGHTH AVE
Practice Address - Street 2:
Practice Address - City:HOWARD LAKE
Practice Address - State:MN
Practice Address - Zip Code:55349
Practice Address - Country:US
Practice Address - Phone:320-543-2345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN001587111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN001587OtherMINNESOTA CHIRO LIC #
MN68093KUOtherINDIVIDUAL PROVIDER #
MN08417KUOtherBCBS CONTRACT PROVIDER #