MEDICARE: COMMONWEALTH CHIROPRACTIC CORPORATION

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

General Provider Information

NPI Number	:	1760989354
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMONWEALTH CHIROPRACTIC CORPORATION

Provider Business Mailing Address
First Line	:	3216 IDAHO AVE S
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55426-3414
Country	:	US
Telephone Number	:	612-730-2906
Fax Number	:

Provider Business Practice Location Address
First Line	:	480 WASHINGTON ST STE 201
Second Line	:
City	:	BRIGHTON
State	:	MA
Zip	:	02135-2655
Country	:	US
Telephone Number	:	617-739-0046
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. TYLER CRABTREE
Credential	:	DC
Telephone Number	:	612-730-2906

Provider Enumeration Date	:	04/10/2018
Last Update Date	:	04/10/2018

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Directions to “COMMONWEALTH CHIROPRACTIC CORPORATION ” Practice Location

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