MEDICARE: DR. MARK F LAVALLIE D.C., D.A.B.C.O.

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	00-1753	MN

General Provider Information

NPI Number	:	1477581742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK F LAVALLIE D.C., D.A.B.C.O.

Provider Business Mailing Address
First Line	:	PO BOX 280337
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55128-9337
Country	:	US
Telephone Number	:	651-432-3806
Fax Number	:	651-739-6029

Provider Business Practice Location Address
First Line	:	261 RUTH ST N
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55119-4337
Country	:	US
Telephone Number	:	651-714-4848
Fax Number	:	651-739-8452

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

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	07/08/2007

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