MEDICARE: LAKES AREA 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	3423	MN

General Provider Information

NPI Number	:	1356576060
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKES AREA CHIROPRACTIC CLINIC LLC

Provider Business Mailing Address
First Line	:	12814 LAKE BLVD
Second Line	:
City	:	LINDSTROM
State	:	MN
Zip	:	55045-9345
Country	:	US
Telephone Number	:	651-257-3900
Fax Number	:	651-257-3932

Provider Business Practice Location Address
First Line	:	12814 LAKE BLVD
Second Line	:
City	:	LINDSTROM
State	:	MN
Zip	:	55045-9345
Country	:	US
Telephone Number	:	651-257-3900
Fax Number	:	651-257-3932

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	MR. ERIK J PETERSON
Credential	:	D.C.
Telephone Number	:	651-257-3900

Provider Enumeration Date	:	05/26/2009
Last Update Date	:	11/11/2009

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