MEDICARE: LISA MELODY ANDRADE L.AC

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	6002853-1201	UT

General Provider Information

NPI Number	:	1588878409
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MELODY ANDRADE L.AC

Provider Business Mailing Address
First Line	:	24 S 600 E
Second Line	:	STE. 2
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1017
Country	:	US
Telephone Number	:	801-521-0531
Fax Number	:	801-521-2654

Provider Business Practice Location Address
First Line	:	24 S 600 E
Second Line	:	STE. 2
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1017
Country	:	US
Telephone Number	:	801-521-0531
Fax Number	:	801-521-2654

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

Provider Enumeration Date	:	05/09/2007
Last Update Date	:	07/08/2007

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