MEDICARE: DR. JOHN ROBERT MACK D.C.

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	4261	MN

General Provider Information

NPI Number	:	1235276221
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN ROBERT MACK D.C.

Provider Business Mailing Address
First Line	:	935 WILDWOOD RD
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55115-1847
Country	:	US
Telephone Number	:	651-779-4263
Fax Number	:	651-779-4274

Provider Business Practice Location Address
First Line	:	935 WILDWOOD RD
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55115-1847
Country	:	US
Telephone Number	:	651-779-4263
Fax Number	:	651-779-4274

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

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	07/09/2007

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