MEDICARE: PREMIER HEALTH OF WEST SAINT PAUL LTD

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

General Provider Information

NPI Number	:	1245983097
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER HEALTH OF WEST SAINT PAUL LTD

Provider Business Mailing Address
First Line	:	205 CESAR CHAVEZ ST
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55107-2309
Country	:	US
Telephone Number	:	651-797-4567
Fax Number	:	651-797-4625

Provider Business Practice Location Address
First Line	:	205 CESAR CHAVEZ ST
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55107-2309
Country	:	US
Telephone Number	:	651-797-4567
Fax Number	:

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	JOSHUA CASTILLO
Credential	:	DC
Telephone Number	:	651-797-4567

Provider Enumeration Date	:	02/01/2022
Last Update Date	:	02/11/2022

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