Healthcare Provider Details

I. General information

NPI: 1912420902
Provider Name (Legal Business Name): AZADEH KHOUBIYARI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2017
Last Update Date: 07/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 ONEIL CT STE 21
COLUMBIA SC
29223-7649
US

IV. Provider business mailing address

6601 LANCER DRIVE
CHARLOTTE NC
28226
US

V. Phone/Fax

Practice location:
  • Phone: 803-888-4034
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3823
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: