Provider Demographics
NPI:1306402003
Name:NAM, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:NAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 E HOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-4404
Mailing Address - Country:US
Mailing Address - Phone:844-467-7763
Mailing Address - Fax:844-760-0321
Practice Address - Street 1:1730 E HOLLY AVE
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-4404
Practice Address - Country:US
Practice Address - Phone:844-467-7763
Practice Address - Fax:844-760-0321
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician