MEDICARE: PDR CHANHASSEN, LTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	111N00000X	Chiropractor
2	111NR0400X	Rehabilitation Chiropractor
3	208100000X	Physical Medicine & Rehabilitation Physician
4	225200000X	Physical Therapy Assistant
5	225X00000X	Occupational Therapist
6	225XP0019X	Physical Rehabilitation Occupational Therapist
7	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1992021851
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PDR CHANHASSEN, LTD

Provider Business Mailing Address
First Line	:	18912 LAKE DR E
Second Line	:
City	:	CHANHASSEN
State	:	MN
Zip	:	55317-9348
Country	:	US
Telephone Number	:	952-908-2730
Fax Number	:	952-908-2731

Provider Business Practice Location Address
First Line	:	18912 LAKE DR E
Second Line	:
City	:	CHANHASSEN
State	:	MN
Zip	:	55317-9348
Country	:	US
Telephone Number	:	952-908-2730
Fax Number	:	952-908-2731

Authorized Official
Title or Position	:	OWNER
Name	:	TODD GINKEL
Credential	:	DC
Telephone Number	:	952-908-2565

Provider Enumeration Date	:	04/15/2010
Last Update Date	:	09/01/2010

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