Provider Demographics
NPI:1225575160
Name:KHEZRIZARDOSHTI, MEHRBANOO
Entity Type:Individual
Prefix:
First Name:MEHRBANOO
Middle Name:
Last Name:KHEZRIZARDOSHTI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5273
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES PENINSULA
Mailing Address - State:CA
Mailing Address - Zip Code:90274-9678
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3661 TORRANCE BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4812
Practice Address - Country:US
Practice Address - Phone:424-360-0066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30309225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist