Healthcare Provider Details

I. General information

NPI: 1962997999
Provider Name (Legal Business Name): NICHOLAS KIETZMAN-GREER DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2018
Last Update Date: 08/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 N SANTA ANITA AVE
ARCADIA CA
91006
US

IV. Provider business mailing address

253 N SANTA ANITA AVE
ARCADIA CA
91006-3114
US

V. Phone/Fax

Practice location:
  • Phone: 626-294-0070
  • Fax:
Mailing address:
  • Phone: 626-294-0070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number294911
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: