Provider Demographics
NPI:1700882719
Name:ERICKSON, LYLE RICHARD (DC)
Entity type:Individual
Prefix:DR
First Name:LYLE
Middle Name:RICHARD
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:PO BOX 930
Mailing Address - Street 2:
Mailing Address - City:WARROAD
Mailing Address - State:MN
Mailing Address - Zip Code:56763-0930
Mailing Address - Country:US
Mailing Address - Phone:218-386-1930
Mailing Address - Fax:218-386-1921
Practice Address - Street 1:201 LAKE ST NW
Practice Address - Street 2:SUITE G,
Practice Address - City:WARROAD
Practice Address - State:MN
Practice Address - Zip Code:56763-2116
Practice Address - Country:US
Practice Address - Phone:218-386-1930
Practice Address - Fax:218-386-1921
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3705111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor