MEDICARE: ENLIGHTEN HOLISTIC MEDICINE, LLC

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	198.001110	IL

General Provider Information

NPI Number	:	1215338066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENLIGHTEN HOLISTIC MEDICINE, LLC

Provider Business Mailing Address
First Line	:	5330 W DEVON AVE
Second Line	:	SUITE 5
City	:	CHICAGO
State	:	IL
Zip	:	60646-4148
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5330 W DEVON AVE
Second Line	:	SUITE 5
City	:	CHICAGO
State	:	IL
Zip	:	60646-4148
Country	:	US
Telephone Number	:	773-682-7124
Fax Number	:

Authorized Official
Title or Position	:	LICENSED ACUPUNCTURIST
Name	:	KELLY MULLEN DESIERTO
Credential	:	L.AC.
Telephone Number	:	773-682-7124

Provider Enumeration Date	:	09/11/2014
Last Update Date	:	09/11/2014

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