Provider Demographics
NPI:1720145907
Name:CARLSON, DEVIN KENNETH (DC)
Entity Type:Individual
Prefix:
First Name:DEVIN
Middle Name:KENNETH
Last Name:CARLSON
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 1:188 OSBORN DR
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-3936
Mailing Address - Country:US
Mailing Address - Phone:701-483-9483
Mailing Address - Fax:701-483-8202
Practice Address - Street 1:188 OSBORN DR
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-3936
Practice Address - Country:US
Practice Address - Phone:701-483-9483
Practice Address - Fax:701-483-8202
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND11468Medicaid
NDU84265Medicare UPIN
ND11468Medicaid