Healthcare Provider Details

I. General information

NPI: 1871773838
Provider Name (Legal Business Name): R SCOTT NANAMURA AC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2007
Last Update Date: 11/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2489 LAKE TAHOE BLVD SUITE 28
S LAKE TAHOE CA
96150-7728
US

IV. Provider business mailing address

PO BOX 9579
S LAKE TAHOE CA
96158-2579
US

V. Phone/Fax

Practice location:
  • Phone: 530-541-6292
  • Fax:
Mailing address:
  • Phone: 530-541-6392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC5974
License Number StateCA

VIII. Authorized Official

Name: R SCOTT NANAMURA
Title or Position: OWNER
Credential: LAC
Phone: 530-541-6392