Provider Demographics
NPI:1407483746
Name:GHAGAR AZADANLOU, MAHTAB (LAC)
Entity Type:Individual
Prefix:MS
First Name:MAHTAB
Middle Name:
Last Name:GHAGAR AZADANLOU
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:MS
Other - First Name:MAHTAB
Other - Middle Name:
Other - Last Name:GHAJAR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:1 CRESTA VERDE DR
Mailing Address - Street 2:
Mailing Address - City:ROLLING HILLS ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-5428
Mailing Address - Country:US
Mailing Address - Phone:310-938-9230
Mailing Address - Fax:
Practice Address - Street 1:3248 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-2719
Practice Address - Country:US
Practice Address - Phone:310-421-8595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18041171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist