=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306371810
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIRANDA CACEK, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2017
-----------------------------------------------------
Last Update Date | 04/23/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 LAKESIDE LN
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80212-7413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-310-8525
-----------------------------------------------------
Fax | 720-360-0266
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 LAKESIDE LN
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80212-7413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-310-8525
-----------------------------------------------------
Fax | 720-360-0266
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, PRACTITIONER
-----------------------------------------------------
Name | MIRANDA LEE CACEK
-----------------------------------------------------
Credential | L.AC, LMT
-----------------------------------------------------
Telephone | 720-310-8525
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MT.0004441
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | ACU0002224
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------