Provider Demographics
NPI:1003019373
Name:KOUSOULIS, NICHOLAS D (DC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:D
Last Name:KOUSOULIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1062 WESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-2903
Mailing Address - Country:US
Mailing Address - Phone:310-208-0101
Mailing Address - Fax:323-512-5228
Practice Address - Street 1:1062 WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-2903
Practice Address - Country:US
Practice Address - Phone:310-208-0101
Practice Address - Fax:323-512-5228
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30570111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABG481AMedicare PIN