MEDICARE: PRAIRIE LIFE CHIROPRACTIC P.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	007606	IA

General Provider Information

NPI Number	:	1639414386
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRAIRIE LIFE CHIROPRACTIC P.C.

Provider Business Mailing Address
First Line	:	715 S MAIN AVE
Second Line	:
City	:	SIOUX CENTER
State	:	IA
Zip	:	51250-1349
Country	:	US
Telephone Number	:	712-717-5101
Fax Number	:	712-717-5102

Provider Business Practice Location Address
First Line	:	715 S MAIN AVE
Second Line	:
City	:	SIOUX CENTER
State	:	IA
Zip	:	51250-1349
Country	:	US
Telephone Number	:	712-717-5101
Fax Number	:	712-717-5102

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DEREK LEE KOSTERS
Credential	:	D.C.
Telephone Number	:	712-717-5101

Provider Enumeration Date	:	12/06/2012
Last Update Date	:	11/04/2021

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