Provider Demographics
NPI:1326399460
Name:NYSTROM, DREW (DAOM, LAC, CMT)
Entity Type:Individual
Prefix:MR
First Name:DREW
Middle Name:
Last Name:NYSTROM
Suffix:
Gender:M
Credentials:DAOM, LAC, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27450 YNEZ RD STE 109
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-4649
Mailing Address - Country:US
Mailing Address - Phone:951-387-4841
Mailing Address - Fax:951-501-3583
Practice Address - Street 1:27450 YNEZ RD STE 109
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-4649
Practice Address - Country:US
Practice Address - Phone:951-387-4841
Practice Address - Fax:951-501-3583
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-28
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA14705171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist