Healthcare Provider Details

I. General information

NPI: 1801829791
Provider Name (Legal Business Name): CAROLYN MOSER NICHOLS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 12/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 ATLANTIC AVE
LONG BEACH CA
90806-1701
US

IV. Provider business mailing address

4401 ATLANTIC AVE SUITE 300
LONG BEACH CA
90807-2218
US

V. Phone/Fax

Practice location:
  • Phone: 562-933-0400
  • Fax:
Mailing address:
  • Phone: 562-481-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA89505
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: