Healthcare Provider Details

I. General information

NPI: 1457043432
Provider Name (Legal Business Name): ALIREZA GHAVAMI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3633 VISTA WAY
OCEANSIDE CA
92056-4568
US

IV. Provider business mailing address

4717 NORWALK DR APT M101
SAN JOSE CA
95129-1488
US

V. Phone/Fax

Practice location:
  • Phone: 760-729-7298
  • Fax:
Mailing address:
  • Phone: 408-425-7973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number304102
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: