Healthcare Provider Details

I. General information

NPI: 1730190901
Provider Name (Legal Business Name): T NIKRAVESH MD CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 04/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6404 WILSHIRE BLVD STE 600
LOS ANGELES CA
90048-5508
US

IV. Provider business mailing address

6404 WILSHIRE BLVD STE 600
LOS ANGELES CA
90048-5508
US

V. Phone/Fax

Practice location:
  • Phone: 310-659-2226
  • Fax: 323-782-8528
Mailing address:
  • Phone: 310-659-2226
  • Fax: 323-782-8528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TANNAZ NIKRAVESH
Title or Position: PRESIDENT
Credential: MD
Phone: 310-659-2226