MEDICARE: AZITA BANOONI D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	22280	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	22280	OTHER	CA	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1902055395
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AZITA BANOONI D.C.

Provider Business Mailing Address
First Line	:	16548 PARK LANE CIR
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-1145
Country	:	US
Telephone Number	:	323-549-0822
Fax Number	:

Provider Business Practice Location Address
First Line	:	16548 PARK LANE CIR
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-1145
Country	:	US
Telephone Number	:	323-549-0822
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2008
Last Update Date	:	09/10/2008

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