Provider Demographics
NPI:1548343288
Name:ANDERSON, LAURIE J (DC DABCO)
Entity type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:J
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DC DABCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 149TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:HAM LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55304-6323
Mailing Address - Country:US
Mailing Address - Phone:763-208-5382
Mailing Address - Fax:
Practice Address - Street 1:16230 ABERDEEN ST NE
Practice Address - Street 2:
Practice Address - City:HAM LAKE
Practice Address - State:MN
Practice Address - Zip Code:55304-5420
Practice Address - Country:US
Practice Address - Phone:763-208-5382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2125111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN077727700Medicaid
MN077727700Medicaid
MN077727700Medicaid
MN350003730Medicare ID - Type UnspecifiedPROVIDER LEVEL MC ID
MN077727700Medicaid
MNT39970Medicare UPIN