MEDICARE: DR. STACY LANE HALLGREN D.C., C.C.E.P., CST

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	798	ND

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	713023	OTHER	ND	PTAN

General Provider Information

NPI Number	:	1407036627
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACY LANE HALLGREN D.C., C.C.E.P., CST

Provider Business Mailing Address
First Line	:	1772 22ND ST NE
Second Line	:
City	:	EMERADO
State	:	ND
Zip	:	58228-9788
Country	:	US
Telephone Number	:	701-594-8497
Fax Number	:

Provider Business Practice Location Address
First Line	:	4350 S WASHINGTON ST
Second Line	:	SUITE 100
City	:	GRAND FORKS
State	:	ND
Zip	:	58201-7184
Country	:	US
Telephone Number	:	701-732-2888
Fax Number	:	701-732-2711

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

Provider Enumeration Date	:	11/05/2007
Last Update Date	:	08/20/2008

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