MEDICARE: LAKE NICOLLET CLINIC, PA

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	1176	MN

General Provider Information

NPI Number	:	1245675511
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE NICOLLET CLINIC, PA

Provider Business Mailing Address
First Line	:	PO BOX 80808
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-8808
Country	:	US
Telephone Number	:	612-259-7570
Fax Number	:	612-886-3427

Provider Business Practice Location Address
First Line	:	ONE WEST LAKE STREET
Second Line	:	SUITE 195
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-3362
Country	:	US
Telephone Number	:	612-259-7570
Fax Number	:	612-886-3427

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. ARTUR VICTOR GUZHAGIN
Credential	:	DC
Telephone Number	:	612-259-7570

Provider Enumeration Date	:	05/01/2013
Last Update Date	:	05/01/2013

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