MEDICARE: DR. DIMITRY JAMES EDISS DC

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	B10698	NV

General Provider Information

NPI Number	:	1871083519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIMITRY JAMES EDISS DC

Provider Business Mailing Address
First Line	:	601 E WASHINGTON ST
Second Line	:
City	:	CARSON CITY
State	:	NV
Zip	:	89701-4064
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	601 E WASHINGTON ST
Second Line	:
City	:	CARSON CITY
State	:	NV
Zip	:	89701-4064
Country	:	US
Telephone Number	:	775-882-7085
Fax Number	:

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

Provider Enumeration Date	:	05/17/2018
Last Update Date	:	05/17/2018

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