Healthcare Provider Details

I. General information

NPI: 1821290552
Provider Name (Legal Business Name): DAVID MOTTAHEDEH DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6399 WILSHIRE BLVD STE 501
LOS ANGELES CA
90048-5708
US

IV. Provider business mailing address

6124 ALCOTT ST APT 4
LOS ANGELES CA
90035-3742
US

V. Phone/Fax

Practice location:
  • Phone: 310-890-1289
  • Fax:
Mailing address:
  • Phone: 310-890-1289
  • Fax: 323-937-3173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberDC30119
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: