MEDICARE: SUSANNAH LEE 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 15007	CA

General Provider Information

NPI Number	:	1043654320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSANNAH LEE L.AC.

Provider Business Mailing Address
First Line	:	2825 PORTER ST
Second Line	:	SUITE B
City	:	SOQUEL
State	:	CA
Zip	:	95073-2467
Country	:	US
Telephone Number	:	831-477-7795
Fax Number	:

Provider Business Practice Location Address
First Line	:	2825 PORTER ST
Second Line	:	SUITE B
City	:	SOQUEL
State	:	CA
Zip	:	95073-2467
Country	:	US
Telephone Number	:	831-477-7795
Fax Number	:

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

Provider Enumeration Date	:	04/17/2013
Last Update Date	:	10/15/2014

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