Healthcare Provider Details

I. General information

NPI: 1699856252
Provider Name (Legal Business Name): SIMON NELSON L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4208 LANKERSHIM BLVD
TOLUCA LAKE CA
91602-2855
US

IV. Provider business mailing address

4208 LANKERSHIM BLVD
TOLUCA LAKE CA
91602-2855
US

V. Phone/Fax

Practice location:
  • Phone: 818-985-7889
  • Fax: 818-985-0954
Mailing address:
  • Phone: 818-985-7889
  • Fax: 818-985-0954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC6147
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: