Provider Demographics
NPI:1407241979
Name:CHIROPRACTIC REHABILITATION CENTER
Entity Type:Organization
Organization Name:CHIROPRACTIC REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAHRZAD
Authorized Official - Middle Name:
Authorized Official - Last Name:FORAT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:818-645-8174
Mailing Address - Street 1:14540 VICTORY BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-1600
Mailing Address - Country:US
Mailing Address - Phone:818-988-7722
Mailing Address - Fax:
Practice Address - Street 1:14540 VICTORY BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411-1600
Practice Address - Country:US
Practice Address - Phone:818-988-7722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-01
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC21323111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty