Provider Demographics
NPI:1861727604
Name:EMBLOM, DUSTIN D (DC)
Entity type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:D
Last Name:EMBLOM
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 1:1011 SECOND STREET NORTH
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ST. CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-3237
Mailing Address - Country:US
Mailing Address - Phone:320-240-0300
Mailing Address - Fax:
Practice Address - Street 1:1011 SECOND STREET NORTH
Practice Address - Street 2:SUITE 202
Practice Address - City:ST. CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-3237
Practice Address - Country:US
Practice Address - Phone:320-240-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5254111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor