MEDICARE: DR. JERRY R WUTZKE D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	338	ND

General Provider Information

NPI Number	:	1134376221
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY R WUTZKE D.C.

Provider Business Mailing Address
First Line	:	1637 SANTA GERTRUDIS LOOP
Second Line	:
City	:	BISMARCK
State	:	ND
Zip	:	58503-0866
Country	:	US
Telephone Number	:	701-255-1955
Fax Number	:

Provider Business Practice Location Address
First Line	:	1637 SANTA GERTRUDIS LOOP
Second Line	:
City	:	BISMARCK
State	:	ND
Zip	:	58503-0866
Country	:	US
Telephone Number	:	701-255-1955
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2008
Last Update Date	:	08/20/2008

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