MEDICARE: LARISA GRANOVSKY 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	DC-006295-L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285620757
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARISA GRANOVSKY DC

Provider Business Mailing Address
First Line	:	842 RED LION RD
Second Line	:	#5
City	:	PHILADELPHIA
State	:	PA
Zip	:	19115-1475
Country	:	US
Telephone Number	:	215-464-0404
Fax Number	:	215-464-0683

Provider Business Practice Location Address
First Line	:	842 RED LION RD
Second Line	:	#5
City	:	PHILADELPHIA
State	:	PA
Zip	:	19115-1475
Country	:	US
Telephone Number	:	215-464-0404
Fax Number	:	215-464-0683

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

Provider Enumeration Date	:	09/21/2005
Last Update Date	:	07/08/2007

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Directions to “ LARISA GRANOVSKY DC” Practice Location

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