Provider Demographics
NPI:1396044632
Name:HOMAYOUN, PEGAH (LAC)
Entity Type:Individual
Prefix:
First Name:PEGAH
Middle Name:
Last Name:HOMAYOUN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7440 GIRARD AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-0010
Mailing Address - Country:US
Mailing Address - Phone:619-321-8214
Mailing Address - Fax:
Practice Address - Street 1:7440 GIRARD AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-0010
Practice Address - Country:US
Practice Address - Phone:619-321-8214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-25
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14092171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist