Provider Demographics
NPI:1790084531
Name:NISS, MICHAEL ROBERT (LAC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:NISS
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 1:4209 SANTA MONICA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-3027
Mailing Address - Country:US
Mailing Address - Phone:323-617-5027
Mailing Address - Fax:323-617-5027
Practice Address - Street 1:4209 SANTA MONICA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-3027
Practice Address - Country:US
Practice Address - Phone:323-617-5027
Practice Address - Fax:323-617-5027
Is Sole Proprietor?:No
Enumeration Date:2011-03-18
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 13957171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist