Provider Demographics
NPI:1912942178
Name:PERREAULT, ROGER E (DC)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:E
Last Name:PERREAULT
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 1:263 W 4TH ST
Mailing Address - Street 2:PO BOX 86
Mailing Address - City:RUSH CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55069
Mailing Address - Country:US
Mailing Address - Phone:320-358-3441
Mailing Address - Fax:320-358-3624
Practice Address - Street 1:263 W 4TH ST
Practice Address - Street 2:
Practice Address - City:RUSH CITY
Practice Address - State:MN
Practice Address - Zip Code:55069
Practice Address - Country:US
Practice Address - Phone:320-358-3441
Practice Address - Fax:320-358-3624
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1666111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
1D067PEOtherBCBSM
230668OtherACN CHIRO CARE
MN511827100Medicaid
T82057Medicare UPIN
MN511827100Medicaid