Provider Demographics
NPI:1902102619
Name:SICILIANO, FRED (LAC(LICENSED ACUPU)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:
Last Name:SICILIANO
Suffix:
Gender:M
Credentials:LAC(LICENSED ACUPU
Other - Prefix:DR
Other - First Name:FRED
Other - Middle Name:
Other - Last Name:SICILIANO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OMD, LAC, MH
Mailing Address - Street 1:PO BOX 26424
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86312-6424
Mailing Address - Country:US
Mailing Address - Phone:805-654-8776
Mailing Address - Fax:
Practice Address - Street 1:9151 E SWIFT TRAIL DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-7346
Practice Address - Country:US
Practice Address - Phone:805-654-8776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-28
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC1315171100000X
AZ0495171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist