=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275772733
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRYSTAL MARIE ALTO D.C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2009
-----------------------------------------------------
Last Update Date | 12/13/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10880 175TH CT W STE 120
-----------------------------------------------------
City | LAKEVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55044-7493
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-693-8798
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10880 175TH CT W SUITE 120
-----------------------------------------------------
City | LAKEVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55044-8781
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-693-8798
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 5184
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------