=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255148490
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | R. NANDAN, M.D., INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2024
-----------------------------------------------------
Last Update Date | 12/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3650 SOUTH ST STE 212
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90712-1528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-272-7630
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3650 SOUTH ST STE 212
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90712-1528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-272-7630
-----------------------------------------------------
Fax | 562-272-7631
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | RAGHU NANDAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 562-272-7630
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------