Provider Demographics
NPI:1700912672
Name:ERICKSON, BETHANY A (DC)
Entity Type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:A
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:BETHANY
Other - Middle Name:A
Other - Last Name:HOLWEGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:2600 GATEWAY AVE.
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503
Mailing Address - Country:US
Mailing Address - Phone:701-751-1161
Mailing Address - Fax:701-751-1332
Practice Address - Street 1:2600 GATEWAY AVE.
Practice Address - Street 2:SUITE 2
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503
Practice Address - Country:US
Practice Address - Phone:701-751-1161
Practice Address - Fax:701-751-1332
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND790111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND14734Medicaid
NDN712441Medicare PIN
NDV11946Medicare UPIN