MEDICARE: DR. JON MICHAEL KOSTELECKY 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	555	ND

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	KOS 18901	OTHER	ND	BLUECROSS BLUESHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720139132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JON MICHAEL KOSTELECKY D.C.

Provider Business Mailing Address
First Line	:	383 15TH ST W
Second Line	:
City	:	DICKINSON
State	:	ND
Zip	:	58601-3017
Country	:	US
Telephone Number	:	701-225-3536
Fax Number	:	701-483-7582

Provider Business Practice Location Address
First Line	:	383 15TH ST W
Second Line	:
City	:	DICKINSON
State	:	ND
Zip	:	58601-3017
Country	:	US
Telephone Number	:	701-225-3536
Fax Number	:	701-483-7582

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

Provider Enumeration Date	:	01/13/2007
Last Update Date	:	07/08/2007

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