Healthcare Provider Details

I. General information

NPI: 1619703394
Provider Name (Legal Business Name): NILOOFAR NIKPOUR LAC, MTOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 09/26/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30131 TOWN CENTER DR STE 270
LAGUNA NIGUEL CA
92677-2082
US

IV. Provider business mailing address

30131 TOWN CENTER DR STE 270
LAGUNA NIGUEL CA
92677-2082
US

V. Phone/Fax

Practice location:
  • Phone: 949-229-5055
  • Fax: 714-362-2337
Mailing address:
  • Phone: 949-229-5055
  • Fax: 714-362-2337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number20174
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: