MEDICARE: GRAND LAKE CHIROPRACTIC PLLC

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	2575	OK

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	:	1174777544
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND LAKE CHIROPRACTIC PLLC

Provider Business Mailing Address
First Line	:	PO BOX 450638
Second Line	:
City	:	GROVE
State	:	OK
Zip	:	74345-0638
Country	:	US
Telephone Number	:	918-786-2442
Fax Number	:	918-786-2634

Provider Business Practice Location Address
First Line	:	240 E 3RD ST
Second Line	:	SUITE C
City	:	GROVE
State	:	OK
Zip	:	74344-7072
Country	:	US
Telephone Number	:	918-786-2442
Fax Number	:	918-786-2634

Authorized Official
Title or Position	:	OWNER
Name	:	DOUGLAS L SCHNELL
Credential	:	D.C.
Telephone Number	:	918-786-2442

Provider Enumeration Date	:	11/11/2008
Last Update Date	:	11/12/2008

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