MEDICARE: TRI-STATE CHIROPRACTIC, PC

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	689	SD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952559916
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI-STATE CHIROPRACTIC, PC

Provider Business Mailing Address
First Line	:	1515 5TH AVE
Second Line	:	SUITE 101
City	:	BELLE FOURCHE
State	:	SD
Zip	:	57717-6031
Country	:	US
Telephone Number	:	605-892-4845
Fax Number	:

Provider Business Practice Location Address
First Line	:	1515 5TH AVE
Second Line	:	SUITE 101
City	:	BELLE FOURCHE
State	:	SD
Zip	:	57717-6031
Country	:	US
Telephone Number	:	605-892-4845
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DOUGLAS J LARSON
Credential	:	DC
Telephone Number	:	605-892-4845

Provider Enumeration Date	:	09/03/2008
Last Update Date	:	09/03/2008

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