Healthcare Provider Details

I. General information

NPI: 1194297069
Provider Name (Legal Business Name): MELINA MOAVEN SHAHIDI DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 WASHINGTON BLVD
JERSEY CITY NJ
07310-1400
US

IV. Provider business mailing address

610 WASHINGTON BLVD
JERSEY CITY NJ
07310-1400
US

V. Phone/Fax

Practice location:
  • Phone: 212-227-3233
  • Fax:
Mailing address:
  • Phone: 212-227-3233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number38MC00758000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: