Healthcare Provider Details

I. General information

NPI: 1336183110
Provider Name (Legal Business Name): ALFRED A DERAKHSHESH D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 09/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 S ROBERTSON BLVD
LOS ANGELES CA
90035-1505
US

IV. Provider business mailing address

1470 REXFORD DR #207
LOS ANGELES CA
90035-3145
US

V. Phone/Fax

Practice location:
  • Phone: 310-652-9283
  • Fax: 310-652-9292
Mailing address:
  • Phone: 310-722-0800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC24112
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: