MEDICARE: PERREAULT CHIROPRACTIC

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	1666	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	230668	OTHER	MN	CHIROPRACTIC CARE OF MN
2	1D067PE	OTHER	MN	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1235223694
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERREAULT CHIROPRACTIC

Provider Business Mailing Address
First Line	:	P O BOX 86
Second Line	:	263 W 4TH ST
City	:	RUSH CITY
State	:	MN
Zip	:	55069
Country	:	US
Telephone Number	:	320-358-3441
Fax Number	:	320-358-3624

Provider Business Practice Location Address
First Line	:	263 W 4TH ST
Second Line	:
City	:	RUSH CITY
State	:	MN
Zip	:	55069
Country	:	US
Telephone Number	:	320-358-3441
Fax Number	:	320-358-3624

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	DR. ROGER E PERREAULT
Credential	:	DC
Telephone Number	:	320-325-3441

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	08/22/2020

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1609959675 — WILLIAM H E KIEPER DDS
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1730223777 — ST CROIX RIVER EDUCATION DISTRICT
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Directions to “PERREAULT CHIROPRACTIC ” Practice Location

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