MEDICARE: MIRANDA MCDONALD L.A.C

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	1509	MN

General Provider Information

NPI Number	:	1043540966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRANDA MCDONALD L.A.C

Provider Business Mailing Address
First Line	:	470 W 78TH ST
Second Line	:	SUITE 120
City	:	CHANHASSEN
State	:	MN
Zip	:	55317-4524
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	470 W 78TH ST
Second Line	:	SUITE 120
City	:	CHANHASSEN
State	:	MN
Zip	:	55317-4524
Country	:	US
Telephone Number	:	952-949-0676
Fax Number	:

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

Provider Enumeration Date	:	12/29/2009
Last Update Date	:	12/29/2009

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