MEDICARE: DR. MADISON GRZESZKOWIAK 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	CHIA1577	ID

General Provider Information

NPI Number	:	1467877811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MADISON GRZESZKOWIAK D.C.

Provider Business Mailing Address
First Line	:	414 S JEFFERSON ST
Second Line	:
City	:	MOSCOW
State	:	ID
Zip	:	83843-2937
Country	:	US
Telephone Number	:	208-596-1105
Fax Number	:	208-883-6559

Provider Business Practice Location Address
First Line	:	414 S JEFFERSON ST
Second Line	:
City	:	MOSCOW
State	:	ID
Zip	:	83843-2937
Country	:	US
Telephone Number	:	208-596-1105
Fax Number	:	208-883-6559

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

Provider Enumeration Date	:	02/21/2014
Last Update Date	:	06/21/2016

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