MEDICARE: WEST METRO WELLNESS, PC

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	MN3585	MN

General Provider Information

NPI Number	:	1609286855
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST METRO WELLNESS, PC

Provider Business Mailing Address
First Line	:	1620 W LAKE ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-3986
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1620 W LAKE ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-3986
Country	:	US
Telephone Number	:	612-822-5973
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JASON ROSS
Credential	:	D.C.
Telephone Number	:	612-822-5973

Provider Enumeration Date	:	04/28/2014
Last Update Date	:	04/28/2014

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