Healthcare Provider Details

I. General information

NPI: 1902071004
Provider Name (Legal Business Name): NICOLAUS GARCIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 04/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 S LAKE AVE STE 284D
PASADENA CA
91101-5074
US

IV. Provider business mailing address

PO BOX 26712
LOS ANGELES CA
90026-0712
US

V. Phone/Fax

Practice location:
  • Phone: 805-622-0279
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: