MEDICARE: KATHLEEN BRODERICK LAC

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	198.000044	IL

General Provider Information

NPI Number	:	1902164866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN BRODERICK LAC

Provider Business Mailing Address
First Line	:	11840 S WESTERN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-4734
Country	:	US
Telephone Number	:	773-233-9000
Fax Number	:

Provider Business Practice Location Address
First Line	:	11840 S WESTERN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-4734
Country	:	US
Telephone Number	:	773-233-9000
Fax Number	:

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

Provider Enumeration Date	:	04/30/2012
Last Update Date	:	04/30/2012

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