MEDICARE: DR. LAWRENCE JOHN GRANLUND 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	0104000909	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	093770	OTHER	VA	PROVIDER NUMBER-ANTHEM

General Provider Information

NPI Number	:	1982693933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAWRENCE JOHN GRANLUND DC

Provider Business Mailing Address
First Line	:	5675 STONE RD
Second Line	:	SUITE 220
City	:	CENTREVILLE
State	:	VA
Zip	:	20120-1667
Country	:	US
Telephone Number	:	703-815-0700
Fax Number	:	703-815-0701

Provider Business Practice Location Address
First Line	:	5675 STONE RD
Second Line	:	SUITE 220
City	:	CENTREVILLE
State	:	VA
Zip	:	20120-1667
Country	:	US
Telephone Number	:	703-815-0700
Fax Number	:	703-815-0701

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

Provider Enumeration Date	:	10/20/2005
Last Update Date	:	07/08/2007

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