MEDICARE: 612 CHIROPRACTIC & WELLNESS

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	6232	MN

General Provider Information

NPI Number	:	1518414382
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	612 CHIROPRACTIC & WELLNESS

Provider Business Mailing Address
First Line	:	2211 MONROE ST NE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55418-3635
Country	:	US
Telephone Number	:	612-578-6001
Fax Number	:

Provider Business Practice Location Address
First Line	:	750 MAIN ST
Second Line	:	SUITE 100
City	:	MENDOTA HEIGHTS
State	:	MN
Zip	:	55118-3764
Country	:	US
Telephone Number	:	612-578-6001
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KELLEY LUMBARD
Credential	:	DC
Telephone Number	:	612-578-6001

Provider Enumeration Date	:	09/08/2016
Last Update Date	:	09/08/2016

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