MEDICARE: GROVELAND CHIROPRACTIC

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	3353	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	22315ES	OTHER	MN	BCBS

General Provider Information

NPI Number	:	1972790269
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GROVELAND CHIROPRACTIC

Provider Business Mailing Address
First Line	:	2052 SAINT CLAIR AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-1650
Country	:	US
Telephone Number	:	651-698-2516
Fax Number	:

Provider Business Practice Location Address
First Line	:	2052 SAINT CLAIR AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-1650
Country	:	US
Telephone Number	:	651-698-2516
Fax Number	:

Authorized Official
Title or Position	:	SOLE PROPRIETOR
Name	:	DR. MARCIA ROEDER
Credential	:	D.C.
Telephone Number	:	651-698-2516

Provider Enumeration Date	:	10/01/2007
Last Update Date	:	10/01/2007

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Directions to “GROVELAND CHIROPRACTIC ” Practice Location

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