MEDICARE: PARVANEH MOHEBAN CLS

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	291U00000X	Clinical Medical Laboratory	MTA44130	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MTA 44130	OTHER	CA	CLS
2	24	OTHER	CA	CLS

General Provider Information

NPI Number	:	1962778480
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PARVANEH MOHEBAN CLS

Provider Business Mailing Address
First Line	:	1407 HILLSIDE DR
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91208-2416
Country	:	US
Telephone Number	:	818-547-9870
Fax Number	:	818-547-9870

Provider Business Practice Location Address
First Line	:	5635 CAHUENGA BLVD
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91601-2104
Country	:	US
Telephone Number	:	818-308-7450
Fax Number	:	818-308-7795

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

Provider Enumeration Date	:	03/29/2012
Last Update Date	:	03/29/2012

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Directions to “ PARVANEH MOHEBAN CLS” Practice Location

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