MEDICARE: ELLEE CARLSON L.AC. LLC

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	198000965	IL

General Provider Information

NPI Number	:	1912203811
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELLEE CARLSON L.AC. LLC

Provider Business Mailing Address
First Line	:	4914 W BALMORAL AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-1506
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6015 N CICERO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-4301
Country	:	US
Telephone Number	:	773-545-9379
Fax Number	:

Authorized Official
Title or Position	:	ORGANIZER/ACUPUNCTURIST
Name	:	ELISABETH L CARLSON
Credential	:	L AC.
Telephone Number	:	773-386-5843

Provider Enumeration Date	:	02/10/2011
Last Update Date	:	02/10/2011

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