MEDICARE: KELLY MULLEN DESIERTO 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	198.001110	IL

General Provider Information

NPI Number	:	1780069831
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY MULLEN DESIERTO L.AC.

Provider Business Mailing Address
First Line	:	5330 W DEVON AVE
Second Line	:	SUITE 5
City	:	CHICAGO
State	:	IL
Zip	:	60646-4148
Country	:	US
Telephone Number	:	773-682-7124
Fax Number	:

Provider Business Practice Location Address
First Line	:	5330 W DEVON AVE
Second Line	:	SUITE 5
City	:	CHICAGO
State	:	IL
Zip	:	60646-4148
Country	:	US
Telephone Number	:	773-682-7124
Fax Number	:

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

Provider Enumeration Date	:	07/29/2015
Last Update Date	:	07/29/2015

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