Provider Demographics
NPI:1477670917
Name:KHALSA, SHAHLA GURUDEV (LAC)
Entity Type:Individual
Prefix:
First Name:SHAHLA
Middle Name:GURUDEV
Last Name:KHALSA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:GURUDEV
Other - Middle Name:KAUR
Other - Last Name:KHALSA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:5880 SAN VICENTE BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-6627
Mailing Address - Country:US
Mailing Address - Phone:323-936-0521
Mailing Address - Fax:
Practice Address - Street 1:5880 SAN VICENTE BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019-6627
Practice Address - Country:US
Practice Address - Phone:323-936-0521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC3357171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist