MEDICARE: BACK ON TRACK REHABILITATION CENTER

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	111NR0400X	Rehabilitation Chiropractor	4468	MN

General Provider Information

NPI Number	:	1780800524
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK ON TRACK REHABILITATION CENTER

Provider Business Mailing Address
First Line	:	1246 32ND AVE N
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56303-1649
Country	:	US
Telephone Number	:	320-230-8920
Fax Number	:	320-230-8922

Provider Business Practice Location Address
First Line	:	1246 32ND AVE N
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56303-1649
Country	:	US
Telephone Number	:	320-230-8920
Fax Number	:	320-230-8922

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MELISSA M LOIDOLT
Credential	:	DC
Telephone Number	:	320-230-8920

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	08/22/2020

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