MEDICARE: EAST STADIUM CHIROPRACTIC WELLNESS CENTER 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	AB009521	MI
2	111N00000X	Chiropractor	BK004737	MI

General Provider Information

NPI Number	:	1649330416
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST STADIUM CHIROPRACTIC WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	2216 MEDFORD RD
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48104-5059
Country	:	US
Telephone Number	:	734-971-1777
Fax Number	:

Provider Business Practice Location Address
First Line	:	2216 MEDFORD RD
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48104-5059
Country	:	US
Telephone Number	:	734-971-1777
Fax Number	:

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	DR. BRIAN L KROES
Credential	:	D.C.
Telephone Number	:	734-971-1777

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	10/21/2011

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