Provider Demographics
NPI:1336506310
Name:LE REVE SPINAL CARE CLINIC CO.
Entity Type:Organization
Organization Name:LE REVE SPINAL CARE CLINIC CO.
Other - Org Name:LE REVE SPINAL CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/ CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AMIR
Authorized Official - Middle Name:ASHKAN
Authorized Official - Last Name:BANISHAHI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:310-795-5265
Mailing Address - Street 1:1827 POWERS FERRY RD SE
Mailing Address - Street 2:BUILDING 7 , SUITE 150
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-5621
Mailing Address - Country:US
Mailing Address - Phone:678-401-3803
Mailing Address - Fax:
Practice Address - Street 1:1827 POWERS FERRY RD SE
Practice Address - Street 2:BUILDING 7 , SUITE 150
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-5621
Practice Address - Country:US
Practice Address - Phone:678-401-3803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-22
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR009638111N00000X, 111NI0013X, 111NI0900X, 111NN0400X, 111NR0200X, 111NR0400X, 111NS0005X, 111NX0800X
CA33704111NI0013X, 111NI0900X, 111NP0017X, 111NR0200X, 111NR0400X, 111NS0005X, 111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NI0013XChiropractic ProvidersChiropractorIndependent Medical ExaminerGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No111NI0900XChiropractic ProvidersChiropractorInternistGroup - Multi-Specialty
No111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Multi-Specialty
No111NP0017XChiropractic ProvidersChiropractorPediatric ChiropractorGroup - Multi-Specialty
No111NR0200XChiropractic ProvidersChiropractorRadiologyGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
No111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Multi-Specialty