Provider Demographics
NPI:1649849795
Name:ERICKSON, LANCE MATTHEW (DC)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:MATTHEW
Last Name:ERICKSON
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 1:7615 WASHINGTON AVE S
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-2417
Mailing Address - Country:US
Mailing Address - Phone:952-300-7177
Mailing Address - Fax:
Practice Address - Street 1:7615 WASHINGTON AVE S
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2417
Practice Address - Country:US
Practice Address - Phone:952-300-7177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6698111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor