MEDICARE: LT PROACTIVE CARE CLINIC NEVADA - FARBAKHSH PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	133V00000X	Registered Dietitian
2	207Q00000X	Family Medicine Physician
3	208000000X	Pediatrics Physician
4	2085B0100X	Body Imaging Physician
5	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1982061750
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LT PROACTIVE CARE CLINIC NEVADA - FARBAKHSH PLLC

Provider Business Mailing Address
First Line	:	2901 CORPORATE PL
Second Line	:
City	:	CHANHASSEN
State	:	MN
Zip	:	55317-4560
Country	:	US
Telephone Number	:	612-554-5257
Fax Number	:

Provider Business Practice Location Address
First Line	:	121 CARNEGIE ST
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89074-7118
Country	:	US
Telephone Number	:	702-802-7357
Fax Number	:	702-802-7356

Authorized Official
Title or Position	:	OWNER/MEDICAL DIRECTOR
Name	:	DR. KAMBIZ FARBAKHSH
Credential	:	M.D.
Telephone Number	:	612-554-5257

Provider Enumeration Date	:	01/25/2016
Last Update Date	:	02/15/2016

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