Healthcare Provider Details

I. General information

NPI: 1306371810
Provider Name (Legal Business Name): MIRANDA CACEK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2017
Last Update Date: 04/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 LAKESIDE LN
DENVER CO
80212-7413
US

IV. Provider business mailing address

16 LAKESIDE LN
DENVER CO
80212-7413
US

V. Phone/Fax

Practice location:
  • Phone: 720-310-8525
  • Fax: 720-360-0266
Mailing address:
  • Phone: 720-310-8525
  • Fax: 720-360-0266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberACU0002224
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT.0004441
License Number StateCO

VIII. Authorized Official

Name: MIRANDA LEE CACEK
Title or Position: OWNER, PRACTITIONER
Credential: L.AC, LMT
Phone: 720-310-8525