MEDICARE: MR. BRENDAN ERIK MATTSON 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	198001059	IL

General Provider Information

NPI Number	:	1851665145
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRENDAN ERIK MATTSON L.AC

Provider Business Mailing Address
First Line	:	4214 N ASHLAND AVE # 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-1202
Country	:	US
Telephone Number	:	773-301-1398
Fax Number	:	773-477-4109

Provider Business Practice Location Address
First Line	:	4214 N ASHLAND AVE # 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-1202
Country	:	US
Telephone Number	:	773-301-1398
Fax Number	:	773-477-4109

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

Provider Enumeration Date	:	03/03/2012
Last Update Date	:	03/03/2012

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