MEDICARE: CITRINE ACUPUNCTURE & HERBAL CLINIC 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	171100000X	Acupuncturist	AC60560608	WA

General Provider Information

NPI Number	:	1063967677
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITRINE ACUPUNCTURE & HERBAL CLINIC LLC

Provider Business Mailing Address
First Line	:	PO BOX 773
Second Line	:
City	:	WHITE SALMON
State	:	WA
Zip	:	98672-0773
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 W STEUBEN ST STE 2A
Second Line	:
City	:	BINGEN
State	:	WA
Zip	:	98605-9175
Country	:	US
Telephone Number	:	509-281-3200
Fax Number	:

Authorized Official
Title or Position	:	ACUPUNCTURIST
Name	:	DR. MIRANDA GENSLER
Credential	:	D.A.O.M, LA.C
Telephone Number	:	503-740-4772

Provider Enumeration Date	:	08/24/2016
Last Update Date	:	08/24/2016

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