=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225428311
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DERAKHSHAN CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2015
-----------------------------------------------------
Last Update Date | 06/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 221 E WALNUT ST SUITE275
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91101-1585
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-765-0555
-----------------------------------------------------
Fax | 626-765-0248
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 221 E WALNUT ST SUITE275
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91101-1585
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-765-0555
-----------------------------------------------------
Fax | 626-765-0248
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SETAREH DERAKHSHAN
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 626-765-0555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC32007
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------