Provider Demographics
NPI:1164678595
Name:NISSIM, ROY (DC)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:
Last Name:NISSIM
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 1:10738 RIVERSIDE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91602-2372
Mailing Address - Country:US
Mailing Address - Phone:818-766-7307
Mailing Address - Fax:
Practice Address - Street 1:10738 RIVERSIDE DR
Practice Address - Street 2:SUITE A
Practice Address - City:TOLUCA LAKE
Practice Address - State:CA
Practice Address - Zip Code:91602-2372
Practice Address - Country:US
Practice Address - Phone:818-766-7307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC30946111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor