Provider Demographics
NPI:1114171022
Name:POURHASSANI, SHABNAM (LAC)
Entity Type:Individual
Prefix:MISS
First Name:SHABNAM
Middle Name:
Last Name:POURHASSANI
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 NEWPORT CENTER DRIVE
Mailing Address - Street 2:SUITE 145
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660
Mailing Address - Country:US
Mailing Address - Phone:949-309-7359
Mailing Address - Fax:949-588-6858
Practice Address - Street 1:180 NEWPORT CENTER DRIVE
Practice Address - Street 2:SUITE 145
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660
Practice Address - Country:US
Practice Address - Phone:949-309-7359
Practice Address - Fax:949-588-6858
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-06
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 12745171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist