Healthcare Provider Details

I. General information

NPI: 1598187635
Provider Name (Legal Business Name): IDA MOLAYEM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2014
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6399 WILSHIRE BLVD STE 110
LOS ANGELES CA
90048-5704
US

IV. Provider business mailing address

6399 WILSHIRE BLVD STE 110
LOS ANGELES CA
90048-5704
US

V. Phone/Fax

Practice location:
  • Phone: 323-951-0999
  • Fax:
Mailing address:
  • Phone: 323-951-0999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License Number32789
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: