=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548712219
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELBY ELISHA JOHNSRUD D.C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2016
-----------------------------------------------------
Last Update Date | 10/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 303 WEST 22ND AVE STE 100
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-846-9600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 303 WEST 22ND AVE STE 100
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-846-9600
-----------------------------------------------------
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 | 6278
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------