Healthcare Provider Details

I. General information

NPI: 1588911150
Provider Name (Legal Business Name): MARJAN RAZI POURDAVOOD D.C., QME
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2012
Last Update Date: 08/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 NORTH CENTRAL AVE SUITE 202
GLENDALE CA
91203
US

IV. Provider business mailing address

610 NORTH CENTRAL AVE SUITE 202
GLENDALE CA
91203
US

V. Phone/Fax

Practice location:
  • Phone: 818-244-6792
  • Fax: 818-244-7477
Mailing address:
  • Phone: 818-244-6792
  • Fax: 818-244-7477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License NumberDC 25093
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: