Provider Demographics
NPI:1154475218
Name:MIRFAKHRAI, ALI (DC)
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:MIRFAKHRAI
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 1:17514 VENTURA BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-3893
Mailing Address - Country:US
Mailing Address - Phone:818-788-4060
Mailing Address - Fax:818-788-1250
Practice Address - Street 1:17514 VENTURA BLVD STE 104
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-3893
Practice Address - Country:US
Practice Address - Phone:818-788-4060
Practice Address - Fax:818-788-1250
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25904111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU78395Medicare UPIN
CADC25904Medicare ID - Type Unspecified
CADC25904Medicare PIN