MEDICARE: SOUTH LAKE CHIROPRACTIC PLLC

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	3950998	MN

General Provider Information

NPI Number	:	1447630223
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH LAKE CHIROPRACTIC PLLC

Provider Business Mailing Address
First Line	:	24000 HIGHWAY 7
Second Line	:	SUITE 215
City	:	EXCELSIOR
State	:	MN
Zip	:	55331-2939
Country	:	US
Telephone Number	:	952-474-2395
Fax Number	:	952-401-1690

Provider Business Practice Location Address
First Line	:	24000 HIGHWAY 7
Second Line	:	SUITE 215
City	:	EXCELSIOR
State	:	MN
Zip	:	55331-2939
Country	:	US
Telephone Number	:	952-474-2395
Fax Number	:	952-401-1690

Authorized Official
Title or Position	:	CEO
Name	:	DR. MICHAEL ISAACSON
Credential	:	DC
Telephone Number	:	952-474-2395

Provider Enumeration Date	:	06/05/2015
Last Update Date	:	06/05/2015

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