MEDICARE: ACUPUNCTURE CLINIC OF MISSOULA INC.

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00986-7	OTHER	MT	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1982723060
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACUPUNCTURE CLINIC OF MISSOULA INC.

Provider Business Mailing Address
First Line	:	3031 S RUSSELL ST
Second Line	:	SUITE 1
City	:	MISSOULA
State	:	MT
Zip	:	59801-8523
Country	:	US
Telephone Number	:	406-728-1600
Fax Number	:	406-327-6702

Provider Business Practice Location Address
First Line	:	3031 S RUSSELL ST
Second Line	:	SUITE 1
City	:	MISSOULA
State	:	MT
Zip	:	59801-8523
Country	:	US
Telephone Number	:	406-728-1600
Fax Number	:	406-327-6702

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DALLAS KEVIN SEABER
Credential	:	L.AC.
Telephone Number	:	406-728-1600

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	05/01/2012

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