=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588709992
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | P TAHERPOUR M.D.INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 124 N VIGNES ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90012-4030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-626-5679
-----------------------------------------------------
Fax | 213-680-0185
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 124 N VIGNES ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90012-4030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-626-5679
-----------------------------------------------------
Fax | 213-680-0185
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CONTROLLER
-----------------------------------------------------
Name | MRS. LILO TAHERPOUR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 213-626-5679
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | A28671
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------