Provider Demographics
NPI:1285830471
Name:MODIR-FATEMI, KIANNA
Entity Type:Individual
Prefix:
First Name:KIANNA
Middle Name:
Last Name:MODIR-FATEMI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIANNA
Other - Middle Name:
Other - Last Name:MODIR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2208 BATAAN RD.
Mailing Address - Street 2:#2
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25825 S. VERMONT AVE.
Practice Address - Street 2:
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710
Practice Address - Country:US
Practice Address - Phone:310-517-2944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25914225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist