Basic Information
| Provider Information | |||||||||
| NPI: | 1639117559 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FRID | ||||||||
| FirstName: | LEON | ||||||||
| MiddleName: | BORIS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | D.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4201 EXCELSIOR BLVD | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554164728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529338900 | ||||||||
| FaxNumber: | 9529459536 | ||||||||
| Practice Location | |||||||||
| Address1: | 3015 UTAH AVE S | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAINT LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554263671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529331121 | ||||||||
| FaxNumber: | 9529459536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 08/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111NX0100X | 2008 | MN | Y | Chiropractic Providers | Chiropractor | Occupational Health |
ID Information
| ID | Type | State | Issuer | Description | 506527500 | 05 | MN | MEDICAID |