Healthcare Provider Details

I. General information

NPI: 1619018850
Provider Name (Legal Business Name): BABAK ROBERT SHAHRESTANI DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 12/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2328 NEWPORT BLVD
COSTA MESA CA
92627-1548
US

IV. Provider business mailing address

2328 NEWPORT BLVD
COSTA MESA CA
92627-1548
US

V. Phone/Fax

Practice location:
  • Phone: 949-631-3139
  • Fax: 949-631-0747
Mailing address:
  • Phone: 949-631-3139
  • Fax: 949-631-0747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number19600
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberDC19600
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: