=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720241714
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEHRZAD KOHANSIEH DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2008
-----------------------------------------------------
Last Update Date | 07/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6317 ROOSEVELT AVE
-----------------------------------------------------
City | WOODSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11377-3641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-335-7700
-----------------------------------------------------
Fax | 718-335-2254
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6317 ROOSEVELT AVE
-----------------------------------------------------
City | WOODSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11377-3641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-335-7700
-----------------------------------------------------
Fax | 718-335-2254
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | X007887
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------