Provider Demographics
NPI:1699856252
Name:NELSON, SIMON (LAC)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:NELSON
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 1:4208 LANKERSHIM BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91602-2855
Mailing Address - Country:US
Mailing Address - Phone:818-985-7889
Mailing Address - Fax:818-985-0954
Practice Address - Street 1:4208 LANKERSHIM BLVD
Practice Address - Street 2:
Practice Address - City:TOLUCA LAKE
Practice Address - State:CA
Practice Address - Zip Code:91602-2855
Practice Address - Country:US
Practice Address - Phone:818-985-7889
Practice Address - Fax:818-985-0954
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC6147171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC6147Medicare ID - Type Unspecified