MEDICARE: MR. BRANDON LAGRECA CAC

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	555-055	WI

General Provider Information

NPI Number	:	1720125867
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRANDON LAGRECA CAC

Provider Business Mailing Address
First Line	:	PO BOX 885
Second Line	:
City	:	EAST TROY
State	:	WI
Zip	:	53120-0885
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3278 MAIN ST
Second Line	:
City	:	EAST TROY
State	:	WI
Zip	:	53120-1152
Country	:	US
Telephone Number	:	262-642-4325
Fax Number	:

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

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	07/13/2017

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