MEDICARE: DR. PHAEDRA IAFANO DC

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	2301009057	MI

General Provider Information

NPI Number	:	1275723702
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHAEDRA IAFANO DC

Provider Business Mailing Address
First Line	:	4270 PLAINFIELD AVE NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-1603
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4270 PLAINFIELD AVE NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-1603
Country	:	US
Telephone Number	:	616-364-6275
Fax Number	:

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

Provider Enumeration Date	:	07/31/2007
Last Update Date	:	10/10/2007

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