MEDICARE: DR. SHANON LEE SIDELL N.D., LAC, LMT

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	175F00000X	Naturopath	171	HI
2	171100000X	Acupuncturist	989	HI
3	175L00000X	Homeopath
4	174H00000X	Health Educator
5	174400000X	Specialist	MAT-4731	HI

General Provider Information

NPI Number	:	1154509578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANON LEE SIDELL N.D., LAC, LMT

Provider Business Mailing Address
First Line	:	PO BOX 383194
Second Line	:
City	:	WAIKOLOA
State	:	HI
Zip	:	96738-3194
Country	:	US
Telephone Number	:	808-960-8333
Fax Number	:	877-992-6761

Provider Business Practice Location Address
First Line	:	68-1845 WAIKOLOA RD
Second Line	:	SUITE #201
City	:	WAIKOLOA
State	:	HI
Zip	:	96738-5584
Country	:	US
Telephone Number	:	808-960-8333
Fax Number	:	877-992-6761

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

Provider Enumeration Date	:	02/07/2008
Last Update Date	:	02/12/2014

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