=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831393172
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHAHLA RAD, MD. INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8642A W PICO BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90035-2314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-289-1114
-----------------------------------------------------
Fax | 310-289-1119
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 18059
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90209-4059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-289-1114
-----------------------------------------------------
Fax | 310-289-1119
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. SHAHLA RAD
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 310-289-1114
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number | A48101
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------