MEDICARE: DAKOTA CHIROPRACTIC & WELLNESS CENTER PROF LLC

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	1008	SD
2	111N00000X	Chiropractor	1009	SD

General Provider Information

NPI Number	:	1992776876
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAKOTA CHIROPRACTIC & WELLNESS CENTER PROF LLC

Provider Business Mailing Address
First Line	:	5124 S WESTERN AVE
Second Line	:	STE 1
City	:	SIOUX FALLS
State	:	SD
Zip	:	57108
Country	:	US
Telephone Number	:	605-339-3300
Fax Number	:	605-339-8880

Provider Business Practice Location Address
First Line	:	5124 S WESTERN AVE
Second Line	:	STE 1
City	:	SIOUX FALLS
State	:	SD
Zip	:	57108
Country	:	US
Telephone Number	:	605-339-3300
Fax Number	:	605-339-8880

Authorized Official
Title or Position	:	MEMBER MANAGER
Name	:	DR. ROBERT GEORGE MCCOY
Credential	:	DC
Telephone Number	:	605-339-3300

Provider Enumeration Date	:	01/30/2006
Last Update Date	:	10/12/2007

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