MEDICARE: DR. ERIC OMDAHL D.C.

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	4958	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	123D50M	OTHER	MN	BLUE CROSS BLUE SHIELD MN

General Provider Information

NPI Number	:	1326268392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIC OMDAHL D.C.

Provider Business Mailing Address
First Line	:	213 E 6TH ST
Second Line	:
City	:	SAINT CHARLES
State	:	MN
Zip	:	55972-1403
Country	:	US
Telephone Number	:	507-932-5696
Fax Number	:

Provider Business Practice Location Address
First Line	:	213 E 6TH ST
Second Line	:
City	:	SAINT CHARLES
State	:	MN
Zip	:	55972-1403
Country	:	US
Telephone Number	:	507-932-5696
Fax Number	:

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

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	02/08/2008

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