Healthcare Provider Details

I. General information

NPI: 1205916459
Provider Name (Legal Business Name): DON NICHOLAS MOY PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1835 S SEPULVEDA BLVD
WEST LOS ANGELES CA
90025-4313
US

IV. Provider business mailing address

134 CHAUTAUQUA BLVD APT. 14
SANTA MONICA CA
90402-1158
US

V. Phone/Fax

Practice location:
  • Phone: 310-478-6222
  • Fax: 310-478-6696
Mailing address:
  • Phone: 310-459-6366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberAT 4835
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: