=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326217266
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. SAM JAHANI D.O.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2008
-----------------------------------------------------
Last Update Date | 02/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 164 W 3RD ST
-----------------------------------------------------
City | DELTA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81416-1842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-874-9977
-----------------------------------------------------
Fax | 970-874-9952
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 164 W 3RD ST
-----------------------------------------------------
City | DELTA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81416-1842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-874-9977
-----------------------------------------------------
Fax | 970-874-9952
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRACTIONER
-----------------------------------------------------
Name | DR. SAM JAHANI
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 970-874-9977
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 38632
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------