MEDICARE: ADVANCED CHIROPRACTIC AND LASER CENTERS, INC

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	2231-012	WI

General Provider Information

NPI Number	:	1548630841
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED CHIROPRACTIC AND LASER CENTERS, INC

Provider Business Mailing Address
First Line	:	3 E MAIN ST
Second Line	:
City	:	BLACK RIVER FALLS
State	:	WI
Zip	:	54615-1408
Country	:	US
Telephone Number	:	715-284-5550
Fax Number	:

Provider Business Practice Location Address
First Line	:	3 E MAIN ST
Second Line	:
City	:	BLACK RIVER FALLS
State	:	WI
Zip	:	54615-1408
Country	:	US
Telephone Number	:	715-284-5550
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TIM SHAW
Credential	:	DC
Telephone Number	:	715-284-5500

Provider Enumeration Date	:	09/29/2015
Last Update Date	:	11/25/2015

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