Provider Demographics
NPI:1114121035
Name:FARVILI, OMID (PT)
Entity Type:Individual
Prefix:
First Name:OMID
Middle Name:
Last Name:FARVILI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6718 ANDASOL AVE
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-5412
Mailing Address - Country:US
Mailing Address - Phone:818-343-2073
Mailing Address - Fax:818-343-2074
Practice Address - Street 1:130 LOUISE ST
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206
Practice Address - Country:US
Practice Address - Phone:818-343-2073
Practice Address - Fax:818-343-2074
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25997225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18994Medicare ID - Type Unspecified