Healthcare Provider Details

I. General information

NPI: 1821438987
Provider Name (Legal Business Name): MIIID INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2013
Last Update Date: 02/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6360 WILSHIRE BLVD STE 414
LOS ANGELES CA
90048-5603
US

IV. Provider business mailing address

6360 WILSHIRE BLVD STE 414
LOS ANGELES CA
90048-5603
US

V. Phone/Fax

Practice location:
  • Phone: 323-397-0897
  • Fax:
Mailing address:
  • Phone: 323-397-0897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA66631
License Number StateCA

VIII. Authorized Official

Name: DR. HOMAYOON KHANLOU
Title or Position: PRESIDENT
Credential: M.D.
Phone: 323-397-0897