MEDICARE: ILENE L CRISTDAHL MD LAC

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	AC2301	CA
2	175F00000X	Naturopath	ND143	CA

General Provider Information

NPI Number	:	1194943183
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ILENE L CRISTDAHL MD LAC

Provider Business Mailing Address
First Line	:	101 PROVIDENCE MINE RD
Second Line	:	SUITE 104
City	:	NEVADA CITY
State	:	CA
Zip	:	95959-2939
Country	:	US
Telephone Number	:	530-470-8707
Fax Number	:	530-852-4996

Provider Business Practice Location Address
First Line	:	101 PROVIDENCE MINE RD
Second Line	:	SUITE 104
City	:	NEVADA CITY
State	:	CA
Zip	:	95959-2939
Country	:	US
Telephone Number	:	530-470-8707
Fax Number	:	530-852-4996

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

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	07/19/2016

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