MEDICARE: DR. JOHN B. DIETRICH II DC

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	3621-012	WI

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

General Provider Information

NPI Number	:	1477607307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN B. DIETRICH II DC

Provider Business Mailing Address
First Line	:	1105 W GRAND AVE
Second Line	:
City	:	WISCONSIN RAPIDS
State	:	WI
Zip	:	54495-3349
Country	:	US
Telephone Number	:	715-423-4050
Fax Number	:	715-424-3108

Provider Business Practice Location Address
First Line	:	1105 W GRAND AVE
Second Line	:
City	:	WISCONSIN RAPIDS
State	:	WI
Zip	:	54495-3349
Country	:	US
Telephone Number	:	715-423-4050
Fax Number	:	715-424-3108

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

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	07/08/2007

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