MEDICARE: DIETRICH CHIROPRACTIC, SC

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	3621-012	WI

General Provider Information

NPI Number	:	1568641116
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIETRICH CHIROPRACTIC, SC

Provider Business Mailing Address
First Line	:	1105 W GRAND AVE
Second Line	:
City	:	WISCONSIN RAPIDS
State	:	WI
Zip	:	54495-3349
Country	:	US
Telephone Number	:	715-423-4050
Fax Number	:	715-424-3108

Provider Business Practice Location Address
First Line	:	1105 W GRAND AVE
Second Line	:
City	:	WISCONSIN RAPIDS
State	:	WI
Zip	:	54495-3349
Country	:	US
Telephone Number	:	715-423-4050
Fax Number	:	715-424-3108

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN B. DIETIRCH II
Credential	:	DC
Telephone Number	:	715-423-4050

Provider Enumeration Date	:	10/31/2007
Last Update Date	:	10/31/2007

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