Provider Demographics
NPI:1255486866
Name:SHAHRAM F. RAVAN, M.D. INC.
Entity Type:Organization
Organization Name:SHAHRAM F. RAVAN, M.D. INC.
Other - Org Name:LIFE WELL INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAHRAM
Authorized Official - Middle Name:F
Authorized Official - Last Name:RAVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-857-0800
Mailing Address - Street 1:436 N BEDFORD DR
Mailing Address - Street 2:SUITE 214
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4310
Mailing Address - Country:US
Mailing Address - Phone:310-858-9200
Mailing Address - Fax:310-271-3793
Practice Address - Street 1:5835 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-7330
Practice Address - Country:US
Practice Address - Phone:323-857-0800
Practice Address - Fax:323-939-7951
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHAHRAM F. RAVAN, M.D., INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-24
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40168225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A401680Medicaid
CA00A401680Medicaid
CA00A401680Medicaid
CAA29065Medicare UPIN