MEDICARE: ROSEVILLE CHIROPRACTIC CLINIC, 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	4755-012	WI
2	111N00000X	Chiropractor	5493	MN

General Provider Information

NPI Number	:	1699054304
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROSEVILLE CHIROPRACTIC CLINIC, LLC

Provider Business Mailing Address
First Line	:	7525 VILLAGE DR STE 110
Second Line	:
City	:	LINO LAKES
State	:	MN
Zip	:	55014-1305
Country	:	US
Telephone Number	:	612-424-5757
Fax Number	:

Provider Business Practice Location Address
First Line	:	7525 VILLAGE DR STE 110
Second Line	:
City	:	LINO LAKES
State	:	MN
Zip	:	55014-1305
Country	:	US
Telephone Number	:	651-247-0941
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JENNIFER KAY MASSA
Credential	:
Telephone Number	:	612-424-5757

Provider Enumeration Date	:	08/11/2011
Last Update Date	:	07/18/2022

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