Provider Demographics
NPI:1700998655
Name:PROUTY, RONALD LEE (DC)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:LEE
Last Name:PROUTY
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 487
Mailing Address - Street 2:
Mailing Address - City:PINE RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:56474-0487
Mailing Address - Country:US
Mailing Address - Phone:218-587-4681
Mailing Address - Fax:218-587-4290
Practice Address - Street 1:2594 TILDEN TRL SW
Practice Address - Street 2:
Practice Address - City:PINE RIVER
Practice Address - State:MN
Practice Address - Zip Code:56474-4041
Practice Address - Country:US
Practice Address - Phone:218-587-4681
Practice Address - Fax:218-587-4290
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2553111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
44G58PROtherBCBS
46G64PROtherBCBS
MN631528300Medicaid
44G58PROtherBCBS
MN631528300Medicaid