=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841455581
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LESLIE ROSE RASTEGAR D.C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2008
-----------------------------------------------------
Last Update Date | 07/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24332 MAIN ST
-----------------------------------------------------
City | NEWHALL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-789-5555
-----------------------------------------------------
Fax | 818-789-7025
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16661 VENTURA BLVD STE. 115
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-1914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-789-5555
-----------------------------------------------------
Fax | 818-789-7025
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC25790
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------