Provider Demographics
NPI:1164920674
Name:MIRHOSSEIN, FARBOD (LAC MSTOM)
Entity Type:Individual
Prefix:
First Name:FARBOD
Middle Name:
Last Name:MIRHOSSEIN
Suffix:
Gender:M
Credentials:LAC MSTOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 ROBINSON DR
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-0902
Mailing Address - Country:US
Mailing Address - Phone:949-701-6903
Mailing Address - Fax:
Practice Address - Street 1:17801 MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6706
Practice Address - Country:US
Practice Address - Phone:949-701-6903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17922171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist