MEDICARE: HEALTHSOURCE OF EDINA, PLLC

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

General Provider Information

NPI Number	:	1366884900
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHSOURCE OF EDINA, PLLC

Provider Business Mailing Address
First Line	:	5107 GUS YOUNG LANE
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55436
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	15670 MICHELE LN
Second Line	:
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55346-2518
Country	:	US
Telephone Number	:	612-396-4520
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	DR. KATIE KEARNEY-BIDWELL
Credential	:	DC
Telephone Number	:	612-396-4520

Provider Enumeration Date	:	07/24/2013
Last Update Date	:	07/24/2013

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