MEDICARE: AUTUMN BEAR 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	0042741	NY
2	171100000X	Acupuncturist	11896562-1201	UT

General Provider Information

NPI Number	:	1942524566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUTUMN BEAR L.AC

Provider Business Mailing Address
First Line	:	5532 LILLEHAMMER LN STE 102
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098-6078
Country	:	US
Telephone Number	:	646-415-1406
Fax Number	:	971-397-0394

Provider Business Practice Location Address
First Line	:	5532 LILLEHAMMER LN STE 102
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098-6078
Country	:	US
Telephone Number	:	435-659-7633
Fax Number	:	971-397-0394

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

Provider Enumeration Date	:	03/25/2010
Last Update Date	:	07/23/2025

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