MEDICARE: ILLUMINNATE FAMILY CHIROPRACTIC, INC.

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	4731	MN

General Provider Information

NPI Number	:	1174730048
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ILLUMINNATE FAMILY CHIROPRACTIC, INC.

Provider Business Mailing Address
First Line	:	8931 HIGHWAY 5
Second Line	:	SUITE A
City	:	LAKE ELMO
State	:	MN
Zip	:	55042-8900
Country	:	US
Telephone Number	:	651-204-0926
Fax Number	:	651-204-3031

Provider Business Practice Location Address
First Line	:	8931 HIGHWAY 5
Second Line	:	SUITE A
City	:	LAKE ELMO
State	:	MN
Zip	:	55042-8900
Country	:	US
Telephone Number	:	651-204-0926
Fax Number	:	651-204-3031

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN CHRISTIAN WARD
Credential	:	D.C.
Telephone Number	:	952-239-0050

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	07/17/2007

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