MEDICARE: KIMBERLY DAVIS MSTOM, 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	198.001181	IL

General Provider Information

NPI Number	:	1881147643
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY DAVIS MSTOM, L.AC

Provider Business Mailing Address
First Line	:	2738 ALYSSA DR
Second Line	:
City	:	NAPERVILLE
State	:	IL
Zip	:	60565-3038
Country	:	US
Telephone Number	:	630-235-8824
Fax Number	:

Provider Business Practice Location Address
First Line	:	1110 N WASHINGTON ST
Second Line	:	RUAH CENTER
City	:	NAPERVILLE
State	:	IL
Zip	:	60563-2767
Country	:	US
Telephone Number	:	630-235-8824
Fax Number	:

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

Provider Enumeration Date	:	07/28/2016
Last Update Date	:	07/28/2016

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