MEDICARE: GRANITE CITY CHIROPRACTIC LLC

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		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	06026803	OTHER	IL	BLUE CROSS & BLUE SHIELD

General Provider Information

NPI Number	:	1528072451
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRANITE CITY CHIROPRACTIC LLC

Provider Business Mailing Address
First Line	:	258 GEREMMA DR
Second Line	:
City	:	BALLWIN
State	:	MO
Zip	:	63011-3334
Country	:	US
Telephone Number	:	314-283-8421
Fax Number	:

Provider Business Practice Location Address
First Line	:	3136 NAMEOKI RD
Second Line	:
City	:	GRANITE CITY
State	:	IL
Zip	:	62040-5013
Country	:	US
Telephone Number	:	618-452-2300
Fax Number	:	618-452-0373

Authorized Official
Title or Position	:	DOCTOR OF CHIROPRACTIC
Name	:	DR. DANIEL JASON MILLER
Credential	:	DC
Telephone Number	:	618-452-2300

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	08/22/2020

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Directions to “GRANITE CITY CHIROPRACTIC LLC ” Practice Location

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