MEDICARE: WANDERING SAGE MEDICINE 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	ACU1624	CO

General Provider Information

NPI Number	:	1326443359
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WANDERING SAGE MEDICINE LLC

Provider Business Mailing Address
First Line	:	PO BOX 18838
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80308-1838
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1371 HECLA DR
Second Line	:	SUITE E
City	:	LOUISVILLE
State	:	CO
Zip	:	80027-2327
Country	:	US
Telephone Number	:	303-530-0488
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TRACIE E DISSINGER
Credential	:	DP.OM
Telephone Number	:	303-530-0488

Provider Enumeration Date	:	11/04/2014
Last Update Date	:	11/04/2014

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Directions to “WANDERING SAGE MEDICINE LLC ” Practice Location

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