Provider Demographics
NPI:1154462935
Name:FARDGHASSEMLOU, HAMIDREZA (PHD, LAC)
Entity Type:Individual
Prefix:DR
First Name:HAMIDREZA
Middle Name:
Last Name:FARDGHASSEMLOU
Suffix:
Gender:M
Credentials:PHD, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10920 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 150-9241
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-3990
Mailing Address - Country:US
Mailing Address - Phone:310-980-6677
Mailing Address - Fax:310-441-1133
Practice Address - Street 1:10920 WILSHIRE BLVD
Practice Address - Street 2:SUITE 150-9241
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-6502
Practice Address - Country:US
Practice Address - Phone:310-980-6677
Practice Address - Fax:310-441-1133
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC4257171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist