Provider Demographics
NPI:1609056662
Name:NANAMURA, R SCOTT (LAC)
Entity Type:Individual
Prefix:
First Name:R
Middle Name:SCOTT
Last Name:NANAMURA
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9579
Mailing Address - Street 2:
Mailing Address - City:S LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96158-2579
Mailing Address - Country:US
Mailing Address - Phone:530-541-6392
Mailing Address - Fax:
Practice Address - Street 1:2489 LAKE TAHOE BLVD
Practice Address - Street 2:SUITE 28
Practice Address - City:S LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-7728
Practice Address - Country:US
Practice Address - Phone:530-541-6392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-07
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC5974171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC5974OtherCALIFORNIA LAC LICENSE