MEDICARE: MR. DAN HAMPTON DEFOREST 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	146055	WI

General Provider Information

NPI Number	:	1336488469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAN HAMPTON DEFOREST L.AC.

Provider Business Mailing Address
First Line	:	305 S MAPLE ST
Second Line	:
City	:	NORTH FREEDOM
State	:	WI
Zip	:	53951-9685
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	307 S MAPLE ST
Second Line	:
City	:	NORTH FREEDOM
State	:	WI
Zip	:	53951-9685
Country	:	US
Telephone Number	:	608-522-5022
Fax Number	:

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

Provider Enumeration Date	:	02/08/2013
Last Update Date	:	02/08/2013

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