MEDICARE: RAPID CITY ACUPUNCTURE 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	AC01246	TX

General Provider Information

NPI Number	:	1528350576
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RAPID CITY ACUPUNCTURE LLC

Provider Business Mailing Address
First Line	:	2720 W MAIN ST
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-8128
Country	:	US
Telephone Number	:	605-791-4001
Fax Number	:	605-791-4001

Provider Business Practice Location Address
First Line	:	2720 W MAIN ST
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-8128
Country	:	US
Telephone Number	:	605-791-4001
Fax Number	:	605-791-4001

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	MR. JESSE LYNN GILLIAM
Credential	:	L.AC
Telephone Number	:	605-415-8739

Provider Enumeration Date	:	05/10/2011
Last Update Date	:	07/05/2012

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