Healthcare Provider Details

I. General information

NPI: 1699175935
Provider Name (Legal Business Name): AMIR KHEDMATIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2014
Last Update Date: 08/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11728 WILSHIRE BLVD APT B707
LOS ANGELES CA
90025-6409
US

IV. Provider business mailing address

11728 WILSHIRE BLVD APT B707
LOS ANGELES CA
90025-6409
US

V. Phone/Fax

Practice location:
  • Phone: 310-991-2647
  • Fax:
Mailing address:
  • Phone: 310-991-2647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number60804
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: