=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871922690
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SYNERGY HEALTHCARE & WELLNESS CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2013
-----------------------------------------------------
Last Update Date | 11/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 SOUTH PACIFIC AVENUE SUITE 101
-----------------------------------------------------
City | SAN PEDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90731-2656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-935-2935
-----------------------------------------------------
Fax | 310-751-7002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1488
-----------------------------------------------------
City | SAN PEDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90733-1488
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-935-2935
-----------------------------------------------------
Fax | 310-751-7002
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. MAHYAR D YADIDI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-666-4721
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number | 31908
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------