1326253972 NPI number — LISA KRISTINE NELSEN, MEDICAL CORPORATION

Table of content: (NPI 1326253972)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326253972 NPI number — LISA KRISTINE NELSEN, MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LISA KRISTINE NELSEN, MEDICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326253972
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3595 N LAKESHORE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOOMIS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95650-8500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-652-6148
Provider Business Mailing Address Fax Number:
916-652-6138

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
151 N SUNRISE AVE
Provider Second Line Business Practice Location Address:
SUITE 1107
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95661-2924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-780-1107
Provider Business Practice Location Address Fax Number:
916-780-7007
Provider Enumeration Date:
05/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NELSEN
Authorized Official First Name:
LISA
Authorized Official Middle Name:
KRISTINE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
916-652-6148

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  A62910 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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