MEDICARE: RAE 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	4444-12	WI

General Provider Information

NPI Number	:	1689087876
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RAE CHIROPRACTIC, LLC

Provider Business Mailing Address
First Line	:	W11199 575TH AVE
Second Line	:
City	:	PRESCOTT
State	:	WI
Zip	:	54021-7636
Country	:	US
Telephone Number	:	715-307-7768
Fax Number	:

Provider Business Practice Location Address
First Line	:	1380 N ACRES RD
Second Line	:
City	:	PRESCOTT
State	:	WI
Zip	:	54021-7061
Country	:	US
Telephone Number	:	715-262-8555
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CARINA RAE PATNODE
Credential	:	D.C.
Telephone Number	:	715-307-7768

Provider Enumeration Date	:	06/05/2014
Last Update Date	:	06/05/2014

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