Healthcare Provider Details

I. General information

NPI: 1376963033
Provider Name (Legal Business Name): MEHRDAD JOUKAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2014
Last Update Date: 07/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 N CENTRAL AVE #610
GLENDALE CA
91203-2052
US

IV. Provider business mailing address

428 W CALIFORNIA AVE UNIT 108
GLENDALE CA
91203-4110
US

V. Phone/Fax

Practice location:
  • Phone: 818-244-6792
  • Fax: 818-244-1703
Mailing address:
  • Phone: 818-244-8875
  • Fax: 818-244-1703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number15905
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: