MEDICARE: LARRY FREDRIC RADKE D.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	CH0002067	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	89714	OTHER	FL	BLUECROSS BLUESHIELD PROV

General Provider Information

NPI Number	:	1649481052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARRY FREDRIC RADKE D.C.

Provider Business Mailing Address
First Line	:	430 SW COLUMBIA AVE
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-5254
Country	:	US
Telephone Number	:	386-752-2252
Fax Number	:	386-754-5088

Provider Business Practice Location Address
First Line	:	430 SW COLUMBIA AVE
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-5254
Country	:	US
Telephone Number	:	386-752-2252
Fax Number	:	386-754-5088

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

Provider Enumeration Date	:	05/25/2007
Last Update Date	:	07/08/2007

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