=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992838577
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REZA TAFAZOLI L.AC.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2007
-----------------------------------------------------
Last Update Date | 11/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2361 CAMPUS DR STE 101
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92612-1463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-679-4111
-----------------------------------------------------
Fax | 949-431-2828
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2361 CAMPUS DR STE 101
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92612-1463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-679-4111
-----------------------------------------------------
Fax | 949-431-2828
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 11603
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------