MEDICARE: DR. LARRY STEVEN BALSIMO DC

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	#2606	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	302L1BA	OTHER	MN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1619066875
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY STEVEN BALSIMO DC

Provider Business Mailing Address
First Line	:	4066 WHITE BEAR AVE N
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-4305
Country	:	US
Telephone Number	:	651-407-0402
Fax Number	:	651-407-0413

Provider Business Practice Location Address
First Line	:	4066 WHITE BEAR AVE N
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-4305
Country	:	US
Telephone Number	:	651-407-0402
Fax Number	:	651-407-0413

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	07/08/2007

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