Healthcare Provider Details

I. General information

NPI: 1659718484
Provider Name (Legal Business Name): NELLIE M ACEVEDO RDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2013
Last Update Date: 06/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9910 LONG BEACH BLVD STE A
LYNWOOD CA
90262-1561
US

IV. Provider business mailing address

1121 E TUCKER ST
COMPTON CA
90221-1282
US

V. Phone/Fax

Practice location:
  • Phone: 323-563-8900
  • Fax:
Mailing address:
  • Phone: 323-246-3894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number56812
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: