MEDICARE: LISA ILENE NICHOLSON L.AC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	AC7347	CA

General Provider Information

NPI Number	:	1548344161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA ILENE NICHOLSON L.AC.

Provider Business Mailing Address
First Line	:	2310 6TH AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-1643
Country	:	US
Telephone Number	:	619-772-4002
Fax Number	:	619-234-4624

Provider Business Practice Location Address
First Line	:	2310 6TH AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-1643
Country	:	US
Telephone Number	:	619-772-4002
Fax Number	:	619-234-4624

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	07/11/2023

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