MEDICARE: R SCOTT NANAMURA AC INC

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	AC5974	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AC 5974	OTHER	CA	CALIFORNIA LAC LICENSE

General Provider Information

NPI Number	:	1871773838
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	R SCOTT NANAMURA AC INC

Provider Business Mailing Address
First Line	:	PO BOX 9579
Second Line	:
City	:	S LAKE TAHOE
State	:	CA
Zip	:	96158-2579
Country	:	US
Telephone Number	:	530-541-6392
Fax Number	:

Provider Business Practice Location Address
First Line	:	2489 LAKE TAHOE BLVD
Second Line	:	SUITE 28
City	:	S LAKE TAHOE
State	:	CA
Zip	:	96150-7728
Country	:	US
Telephone Number	:	530-541-6292
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	R SCOTT NANAMURA
Credential	:	LAC
Telephone Number	:	530-541-6392

Provider Enumeration Date	:	11/07/2007
Last Update Date	:	11/07/2007

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