Healthcare Provider Details

I. General information

NPI: 1801266499
Provider Name (Legal Business Name): LT PROACTIVE CARE CLINIC CALIFORNIA, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2015
Last Update Date: 09/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1435 EAST ROSEVILLE PKWY
ROSEVILLE CA
95661
US

IV. Provider business mailing address

1435 EAST ROSEVILLE PKWY
ROSEVILLE CA
95661
US

V. Phone/Fax

Practice location:
  • Phone: 916-472-2057
  • Fax: 916-472-2058
Mailing address:
  • Phone: 916-472-2057
  • Fax: 916-472-2058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KAMBIZ FARBAKHSH
Title or Position: OWNER/MEDICAL DIRECTOR
Credential: M.D.
Phone: 952-541-7157