MEDICARE: JADE CLOUD

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	1618	MN

General Provider Information

NPI Number	:	1114366051
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JADE CLOUD

Provider Business Mailing Address
First Line	:	24000 HIGHWAY 7
Second Line	:	SUITE 220
City	:	EXCELSIOR
State	:	MN
Zip	:	55331-2939
Country	:	US
Telephone Number	:	651-214-5525
Fax Number	:

Provider Business Practice Location Address
First Line	:	24000 HIGHWAY 7
Second Line	:	SUITE 220
City	:	EXCELSIOR
State	:	MN
Zip	:	55331-2939
Country	:	US
Telephone Number	:	651-214-5525
Fax Number	:

Authorized Official
Title or Position	:	OWNER/LICENSED ACUPUNCTURIST
Name	:	MS. RHEA MARIE DYKOSKI
Credential	:	L.AC., DIPL.O.M.
Telephone Number	:	651-214-5525

Provider Enumeration Date	:	06/24/2013
Last Update Date	:	06/24/2013

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