=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851808075
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HENGAMEH EBRAHIMI LAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2018
-----------------------------------------------------
Last Update Date | 01/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29571 MICHELIS ST
-----------------------------------------------------
City | LAGUNA NIGUEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92677-1686
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-324-6289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30025 ALICIA PKWY STE 301
-----------------------------------------------------
City | LAGUNA NIGUEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92677-2090
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-324-6289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 16799
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------