Healthcare Provider Details

I. General information

NPI: 1104619071
Provider Name (Legal Business Name): PANTEHA PARTOVI PA-C CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2025
Last Update Date: 05/23/2025
Certification Date: 05/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11600 WILSHIRE BLVD STE 322
LOS ANGELES CA
90025-1783
US

IV. Provider business mailing address

11600 WILSHIRE BLVD STE 322
LOS ANGELES CA
90025-1783
US

V. Phone/Fax

Practice location:
  • Phone: 310-688-8800
  • Fax:
Mailing address:
  • Phone: 310-688-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. PANTEHA PARTOVI
Title or Position: CEO
Credential: PA
Phone: 310-688-8800