MEDICARE: MELISSA B LIGHT MSOM, TXLAC

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	AC00701	TX

General Provider Information

NPI Number	:	1073765996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA B LIGHT MSOM, TXLAC

Provider Business Mailing Address
First Line	:	2502 MANOR RD
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78722-2007
Country	:	US
Telephone Number	:	512-775-4057
Fax Number	:

Provider Business Practice Location Address
First Line	:	2502 MANOR RD
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78722-2007
Country	:	US
Telephone Number	:	512-775-4057
Fax Number	:

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

Provider Enumeration Date	:	10/22/2008
Last Update Date	:	10/22/2008

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