Provider Demographics
NPI:1063174670
Name:NOLASCO, ELI SAMUEL
Entity type:Individual
Prefix:
First Name:ELI
Middle Name:SAMUEL
Last Name:NOLASCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 AVERRELL AVE
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22603-5822
Mailing Address - Country:US
Mailing Address - Phone:540-409-7139
Mailing Address - Fax:
Practice Address - Street 1:80 MADDEX DR
Practice Address - Street 2:
Practice Address - City:SHEPHERDSTOWN
Practice Address - State:WV
Practice Address - Zip Code:25443-4305
Practice Address - Country:US
Practice Address - Phone:304-876-9422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVC2395224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant