Provider Demographics
NPI:1306371810
Name:MIRANDA CACEK, LLC
Entity Type:Organization
Organization Name:MIRANDA CACEK, LLC
Other - Org Name:BODYWISDOM ACUPUNCTURE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:CACEK
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, LMT
Authorized Official - Phone:720-310-8525
Mailing Address - Street 1:16 LAKESIDE LN
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80212-7413
Mailing Address - Country:US
Mailing Address - Phone:720-310-8525
Mailing Address - Fax:720-360-0266
Practice Address - Street 1:16 LAKESIDE LN
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80212-7413
Practice Address - Country:US
Practice Address - Phone:720-310-8525
Practice Address - Fax:720-360-0266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-23
Last Update Date:2017-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU0002224171100000X
COMT.0004441225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty