MEDICARE: FORMLESS FORM QIGONG & ACUPUNCTURE

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	1588	MN

General Provider Information

NPI Number	:	1306199864
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORMLESS FORM QIGONG & ACUPUNCTURE

Provider Business Mailing Address
First Line	:	5603 CHICAGO AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55417-2429
Country	:	US
Telephone Number	:	612-708-0753
Fax Number	:

Provider Business Practice Location Address
First Line	:	5603 CHICAGO AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55417-2429
Country	:	US
Telephone Number	:	612-708-0753
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PENG RODEN HER
Credential	:	LAC
Telephone Number	:	612-708-0753

Provider Enumeration Date	:	10/22/2012
Last Update Date	:	03/01/2018

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