MEDICARE: VASA MIK 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	AC 11520	CA

General Provider Information

NPI Number	:	1003057761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VASA MIK L.AC

Provider Business Mailing Address
First Line	:	1804 CABLE ST STE B
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92107-3103
Country	:	US
Telephone Number	:	619-243-5109
Fax Number	:	619-243-5113

Provider Business Practice Location Address
First Line	:	1804 CABLE ST STE B
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92107-3103
Country	:	US
Telephone Number	:	619-243-5109
Fax Number	:	619-243-5113

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

Provider Enumeration Date	:	03/10/2009
Last Update Date	:	03/10/2009

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