MEDICARE: MR. PENG RODEN HER 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	1588	MN

General Provider Information

NPI Number	:	1760733885
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PENG RODEN HER L.AC.

Provider Business Mailing Address
First Line	:	4357 30TH AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-3710
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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2012
Last Update Date	:	03/01/2018

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