MEDICARE: LANDRY CHIROPRACTIC INC.

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	3805	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	45D48LA	OTHER	MN	BCBS PIN
2	94631	OTHER	MN	HEALTH PARTNERS ID.
3	4487073	OTHER	MN	MEDICA ID.

General Provider Information

NPI Number	:	1467642843
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LANDRY CHIROPRACTIC INC.

Provider Business Mailing Address
First Line	:	19449 EVANS ST NW
Second Line	:	SUITE A
City	:	ELK RIVER
State	:	MN
Zip	:	55330-1074
Country	:	US
Telephone Number	:	612-702-9012
Fax Number	:	736-633-0039

Provider Business Practice Location Address
First Line	:	19449 EVANS ST NW
Second Line	:	SUITE A
City	:	ELK RIVER
State	:	MN
Zip	:	55330-1074
Country	:	US
Telephone Number	:	612-702-9012
Fax Number	:	736-633-0039

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	DR. PETER ALBERT LANDRY
Credential	:	D.C.
Telephone Number	:	612-702-9012

Provider Enumeration Date	:	07/31/2007
Last Update Date	:	07/31/2007

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