MEDICARE: DR. GRANT ERICKSON 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	3100	MN
2	111N00000X	Chiropractor	2967	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	68541	OTHER	ARAZ
2	0238	OTHER	HSM
3	231600	OTHER	ACN
4	272GOER	OTHER	BCBS - INDIVIDUAL

General Provider Information

NPI Number	:	1932275815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GRANT ERICKSON D.C.

Provider Business Mailing Address
First Line	:	4635 WHITE BEAR PKWY
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-3300
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4635 WHITE BEAR PKWY
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-3300
Country	:	US
Telephone Number	:	651-429-5329
Fax Number	:	651-429-2759

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

Provider Enumeration Date	:	11/24/2006
Last Update Date	:	07/09/2007

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Directions to “ DR. GRANT ERICKSON D.C.” Practice Location

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