MEDICARE: DR. MITRA GOOSHEH PH.D, LAC, MSOM

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	171100000X	Acupuncturist	14271	CA

General Provider Information

NPI Number	:	1306106414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MITRA GOOSHEH PH.D, LAC, MSOM

Provider Business Mailing Address
First Line	:	918 S ROBERTSON BLVD
Second Line	:	#1
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-1611
Country	:	US
Telephone Number	:	310-657-0911
Fax Number	:

Provider Business Practice Location Address
First Line	:	918 S ROBERTSON BLVD
Second Line	:	#1
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-1611
Country	:	US
Telephone Number	:	310-657-0911
Fax Number	:

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

Provider Enumeration Date	:	05/22/2012
Last Update Date	:	05/22/2012

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