Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NS0005X | Chiropractic Sports Physician | 33159 | CA |
NPI | 1003206129 |
---|---|
Provider Name | Majed Andre Nagoulat |
First Address | Highland, CA 92346-1614 |
Second Address | Riverside, CA 92506-1895 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/01/2015 |
Last Update Date | 27/01/2015 |