MEDICARE: KOSTELECKY CHIROPRACTIC CLINIC INC

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	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952442782
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOSTELECKY CHIROPRACTIC CLINIC INC

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	:

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	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JON MICHAEL KOSTELECKY
Credential	:	D.C.
Telephone Number	:	701-225-3536

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	04/20/2011

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