Provider Information for 1083047195
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KIA NICHELLE
Sex: Female
NPI: 1083047195
Last Updated: 2020-12-03
Certification Date: 2020-12-03
Certification Date: 2020-12-03
Details
| Name | Value | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| NPI | 1083047195 | ||||||||||||
| Enumeration Date | 2013-08-12 | ||||||||||||
| NPI Type | NPI-1 Individual | ||||||||||||
| Sole Proprietor | YES | ||||||||||||
| Status | Active | ||||||||||||
| Mailing Address | 9825 MAGNOLIA AVE STE B RIVERSIDE, CA 92503-3565 United States Phone: 951-509-2499 | Fax: | ||||||||||||
| Primary Practice Address | 224 W GRAHAM AVE LAKE ELSINORE, CA 92530-3740 United States Phone: 951-318-1351 | Fax: | ||||||||||||
| Secondary Practice Address(es) | 1514 MARIGOLD DR 9890 COUNTY FARM RD STE B | ||||||||||||
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