Provider Demographics
NPI:1124017264
Name:JALILI, ASHKAN (DC)
Entity Type:Individual
Prefix:DR
First Name:ASHKAN
Middle Name:
Last Name:JALILI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 15TH ST
Mailing Address - Street 2:218
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-1809
Mailing Address - Country:US
Mailing Address - Phone:310-394-9436
Mailing Address - Fax:310-394-5765
Practice Address - Street 1:1304 15TH ST
Practice Address - Street 2:218
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1809
Practice Address - Country:US
Practice Address - Phone:310-394-9436
Practice Address - Fax:310-394-5765
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC20980111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0280980OtherBLUE SHIELD
CAU91109Medicare UPIN