MEDICARE: MR. BRANDON RAY CRANDALL 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	1348-012	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154321727
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRANDON RAY CRANDALL DC

Provider Business Mailing Address
First Line	:	1831 W COURT ST
Second Line	:	STE 1
City	:	JANESVILLE
State	:	WI
Zip	:	53548-3406
Country	:	US
Telephone Number	:	608-754-7463
Fax Number	:	608-754-1437

Provider Business Practice Location Address
First Line	:	1831 W COURT ST
Second Line	:	STE 1
City	:	JANESVILLE
State	:	WI
Zip	:	53548-3406
Country	:	US
Telephone Number	:	608-754-7463
Fax Number	:	608-754-1437

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

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	07/08/2007

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