Healthcare Provider Details

I. General information

NPI: 1992852537
Provider Name (Legal Business Name): NICOLE BRADSHAW L. AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11638 VENTURA BLVD UNIT B
STUDIO CITY CA
91604-2653
US

IV. Provider business mailing address

10061 RIVERSIDE DRIVE #811
TOLUCA LAKE CA
91602
US

V. Phone/Fax

Practice location:
  • Phone: 818-509-9233
  • Fax: 818-509-9799
Mailing address:
  • Phone: 818-509-9233
  • Fax: 818-509-9799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC 8406
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: