Provider Demographics
NPI:1649425398
Name:BURDOCK, NICOLE (LAC)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:BURDOCK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 WILSHIRE BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5678
Mailing Address - Country:US
Mailing Address - Phone:310-453-8668
Mailing Address - Fax:
Practice Address - Street 1:1457 ARMACOST AVE
Practice Address - Street 2:UNIT 202
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-2227
Practice Address - Country:US
Practice Address - Phone:310-755-4772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-21
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC12316171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist