Provider Demographics
NPI:1841523123
Name:NISHIYA, KENICHI (LAC)
Entity type:Individual
Prefix:
First Name:KENICHI
Middle Name:
Last Name:NISHIYA
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 1:1915 S AUSTIN AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-7843
Mailing Address - Country:US
Mailing Address - Phone:512-868-9109
Mailing Address - Fax:
Practice Address - Street 1:1915 S AUSTIN AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-7843
Practice Address - Country:US
Practice Address - Phone:512-868-9109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-17
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC00922171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist