Healthcare Provider Details

I. General information

NPI: 1578884649
Provider Name (Legal Business Name): KOUSHA HARIRCHIAN LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2010
Last Update Date: 06/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14423 HAMLIN ST
VAN NUYS CA
91401-1410
US

IV. Provider business mailing address

6520 PLATT AVE # 265
WEST HILLS CA
91307-3218
US

V. Phone/Fax

Practice location:
  • Phone: 310-855-3392
  • Fax:
Mailing address:
  • Phone: 310-855-3392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC9405
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: