Healthcare Provider Details

I. General information

NPI: 1417025511
Provider Name (Legal Business Name): MARYAM BANA MANSOURI OMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14785 JEFFREY RD STE 102
IRVINE CA
92618
US

IV. Provider business mailing address

16 LANCEWOOD WAY
IRVINE CA
92612
US

V. Phone/Fax

Practice location:
  • Phone: 949-651-0044
  • Fax:
Mailing address:
  • Phone: 949-302-5921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC8145
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: