MEDICARE: NICOLE GLATHE L.AC. DIPL.O.M.

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	17658	CA

General Provider Information

NPI Number	:	1831626365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE GLATHE L.AC. DIPL.O.M.

Provider Business Mailing Address
First Line	:	1440 VETERAN AVE APT 371
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-4854
Country	:	US
Telephone Number	:	707-337-9912
Fax Number	:

Provider Business Practice Location Address
First Line	:	915 S CATALINA AVE STE B
Second Line	:
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-4795
Country	:	US
Telephone Number	:	707-337-9912
Fax Number	:

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

Provider Enumeration Date	:	05/15/2017
Last Update Date	:	03/17/2018

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