MEDICARE: DR. MARYAM BOUSHEHRI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	11817	TX

General Provider Information

NPI Number	:	1205061058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARYAM BOUSHEHRI

Provider Business Mailing Address
First Line	:	PO BOX 894
Second Line	:
City	:	CEDAR PARK
State	:	TX
Zip	:	78630-0894
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1640 HIGHLAND FALLS DR STE 701
Second Line	:
City	:	LEANDER
State	:	TX
Zip	:	78641-4842
Country	:	US
Telephone Number	:	512-774-0174
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2009
Last Update Date	:	01/03/2022

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