Healthcare Provider Details

I. General information

NPI: 1366171779
Provider Name (Legal Business Name): MIRA TAKHALOVA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 06/09/2022
Certification Date: 06/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8445 VERNON AVENUE #309
LOS ANGELES CA
90067-4565
US

IV. Provider business mailing address

1155 N GARDNER ST APT 302
WEST HOLLYWOOD CA
90046-5623
US

V. Phone/Fax

Practice location:
  • Phone: 323-633-6363
  • Fax:
Mailing address:
  • Phone: 323-509-8192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number586479
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: