MEDICARE: MR. KAI ROND VAN BODEGOM-SMITH 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	16102	CA

General Provider Information

NPI Number	:	1265823603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KAI ROND VAN BODEGOM-SMITH L.AC.

Provider Business Mailing Address
First Line	:	4010 FORNEY AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92117-4630
Country	:	US
Telephone Number	:	858-539-6496
Fax Number	:

Provider Business Practice Location Address
First Line	:	16776 BERNARDO CENTER DR
Second Line	:	SUITE 101
City	:	SAN DIEGO
State	:	CA
Zip	:	92128-2534
Country	:	US
Telephone Number	:	858-673-1733
Fax Number	:

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

Provider Enumeration Date	:	02/06/2015
Last Update Date	:	02/06/2015

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