MEDICARE: SHAHBA BODY REVIVE CHIROPRACTIC CORPORATION

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

General Provider Information

NPI Number	:	1538889373
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHAHBA BODY REVIVE CHIROPRACTIC CORPORATION

Provider Business Mailing Address
First Line	:	4132 KATELLA AVE STE 102
Second Line	:
City	:	LOS ALAMITOS
State	:	CA
Zip	:	90720-3491
Country	:	US
Telephone Number	:	562-596-9677
Fax Number	:	562-795-6630

Provider Business Practice Location Address
First Line	:	4132 KATELLA AVE STE 102
Second Line	:
City	:	LOS ALAMITOS
State	:	CA
Zip	:	90720-3491
Country	:	US
Telephone Number	:	818-912-8070
Fax Number	:	562-795-6630

Authorized Official
Title or Position	:	PROVIDER
Name	:	DR. REZA SHAHBA
Credential	:	DC
Telephone Number	:	818-912-8070

Provider Enumeration Date	:	08/31/2022
Last Update Date	:	03/15/2024

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