MEDICARE: BIRCH LAKE CHIROPRACTIC CLINIC, LLC

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	751	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	273GOBI	OTHER	BCBS - CLINIC #
2	231600	OTHER	ACN
3	6763511-00	OTHER	MHCP

General Provider Information

NPI Number	:	1255407136
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BIRCH LAKE CHIROPRACTIC CLINIC, LLC

Provider Business Mailing Address
First Line	:	4635 WHITE BEAR PKWY
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-3300
Country	:	US
Telephone Number	:	651-429-5329
Fax Number	:	651-429-2759

Provider Business Practice Location Address
First Line	:	4635 WHITE BEAR PKWY
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-3300
Country	:	US
Telephone Number	:	651-429-5329
Fax Number	:	651-429-2759

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GRANT ERICKSON
Credential	:	D.C.
Telephone Number	:	651-429-5329

Provider Enumeration Date	:	11/24/2006
Last Update Date	:	03/17/2010

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