=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689374027
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHAFA PSYCHIATRIC AND CONSULTING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2023
-----------------------------------------------------
Last Update Date | 03/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 265 S RANDOLPH AVE STE 290
-----------------------------------------------------
City | BREA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92821-5702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 657-341-4422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1400 N KRAEMER BLVD UNIT 171
-----------------------------------------------------
City | PLACENTIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92871-1408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 657-341-4422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO PRESIDENT
-----------------------------------------------------
Name | KHOSRAVI GOHAR
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 657-341-4422
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------