MEDICARE: KENNETH DRAKE

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	0002004	CO

General Provider Information

NPI Number	:	1780074591
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH DRAKE

Provider Business Mailing Address
First Line	:	563 BAKEMAN LN
Second Line	:
City	:	ARROYO GRANDE
State	:	CA
Zip	:	93420-3752
Country	:	US
Telephone Number	:	805-710-9184
Fax Number	:

Provider Business Practice Location Address
First Line	:	1124 NIPOMO ST STE C
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93401-3883
Country	:	US
Telephone Number	:	805-202-1492
Fax Number	:

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

Provider Enumeration Date	:	02/01/2015
Last Update Date	:	03/17/2018

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Directions to “ KENNETH DRAKE ” Practice Location

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