MEDICARE: DEREK MARRONGELLE DACM, L.AC., CCN

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	LAC-010133	AZ
2	133N00000X	Nutritionist	5063

General Provider Information

NPI Number	:	1417581539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK MARRONGELLE DACM, L.AC., CCN

Provider Business Mailing Address
First Line	:	113 PINE CREEK DR
Second Line	:
City	:	ORWIGSBURG
State	:	PA
Zip	:	17961-9135
Country	:	US
Telephone Number	:	570-617-9005
Fax Number	:

Provider Business Practice Location Address
First Line	:	16421 N TATUM BLVD STE 210
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032-3457
Country	:	US
Telephone Number	:	570-617-9005
Fax Number	:

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

Provider Enumeration Date	:	02/27/2020
Last Update Date	:	08/25/2020

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