MEDICARE: MS. NELLIE M ACEVEDO RDA

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	126800000X	Dental Assistant	56812	CA

General Provider Information

NPI Number	:	1659718484
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. NELLIE M ACEVEDO RDA

Provider Business Mailing Address
First Line	:	1121 E TUCKER ST
Second Line	:
City	:	COMPTON
State	:	CA
Zip	:	90221-1282
Country	:	US
Telephone Number	:	323-246-3894
Fax Number	:

Provider Business Practice Location Address
First Line	:	9910 LONG BEACH BLVD STE A
Second Line	:
City	:	LYNWOOD
State	:	CA
Zip	:	90262-1561
Country	:	US
Telephone Number	:	323-563-8900
Fax Number	:

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

Provider Enumeration Date	:	06/03/2013
Last Update Date	:	06/03/2013

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