Provider Demographics
NPI:1093035545
Name:HARIDOPOLOS, NICHOLAS JR (LAC)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:
Last Name:HARIDOPOLOS
Suffix:JR
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 1:25 19TH AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-4154
Mailing Address - Country:US
Mailing Address - Phone:310-904-8425
Mailing Address - Fax:
Practice Address - Street 1:25 19TH AVE
Practice Address - Street 2:SUITE E
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-4154
Practice Address - Country:US
Practice Address - Phone:310-904-8425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-07
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8866171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist