MEDICARE: ARVIDSON GRAND AVE CHIROPRACTIC

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	2049	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	23175AR	OTHER	MN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1245373034
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARVIDSON GRAND AVE CHIROPRACTIC

Provider Business Mailing Address
First Line	:	1119 GRAND AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-2629
Country	:	US
Telephone Number	:	651-224-7603
Fax Number	:	651-224-2604

Provider Business Practice Location Address
First Line	:	1119 GRAND AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-2629
Country	:	US
Telephone Number	:	651-224-7603
Fax Number	:	651-224-2604

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	DR. CRAIG GEORGE ARVIDSON
Credential	:	DC
Telephone Number	:	651-224-7603

Provider Enumeration Date	:	02/14/2007
Last Update Date	:	02/14/2008

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1093845679 — JACQUELINE SUZANNE DENISON GETCHIUS B.A.
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