Healthcare Provider Details

I. General information

NPI: 1962778480
Provider Name (Legal Business Name): PARVANEH MOHEBAN CLS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PARVANEH MOHEBAN CLS

II. Dates (important events)

Enumeration Date: 03/29/2012
Last Update Date: 03/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5635 CAHUENGA BLVD
NORTH HOLLYWOOD CA
91601-2104
US

IV. Provider business mailing address

1407 HILLSIDE DR
GLENDALE CA
91208-2416
US

V. Phone/Fax

Practice location:
  • Phone: 818-308-7450
  • Fax: 818-308-7795
Mailing address:
  • Phone: 818-547-9870
  • Fax: 818-547-9870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberMTA44130
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: