MEDICARE: NORTHERN CHIROPRACTIC AND WELLNESS CENTER LLC

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	261QM1300X	Multi-Specialty Clinic/Center	6001	MN

General Provider Information

NPI Number	:	1134678410
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHERN CHIROPRACTIC AND WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	730 APOLLO DR
Second Line	:	SUITE 120
City	:	LINO LAKES
State	:	MN
Zip	:	55014-3037
Country	:	US
Telephone Number	:	651-797-3756
Fax Number	:

Provider Business Practice Location Address
First Line	:	730 APOLLO DR
Second Line	:	SUITE 120
City	:	LINO LAKES
State	:	MN
Zip	:	55014-3037
Country	:	US
Telephone Number	:	651-797-3756
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. TYLER PAUL HANSON
Credential	:	D.C.
Telephone Number	:	651-797-3756

Provider Enumeration Date	:	09/27/2016
Last Update Date	:	12/15/2016

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