Healthcare Provider Details

I. General information

NPI: 1750402574
Provider Name (Legal Business Name): GENETIC INSTITUTE OF ANTI AGING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 PAULARINO AVE SUITE 100
COSTA MESA CA
92626-2940
US

IV. Provider business mailing address

720 PAULARINO AVE SUITE 100
COSTA MESA CA
92626-2940
US

V. Phone/Fax

Practice location:
  • Phone: 714-641-2640
  • Fax: 714-641-2646
Mailing address:
  • Phone: 714-641-2640
  • Fax: 714-641-2646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170100000X
TaxonomyPh.D. Medical Genetics
License NumberG77981
License Number StateCA

VIII. Authorized Official

Name: DR. MOHAMMAD SAEED KHARAZMI
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 714-641-2640