Provider Demographics
NPI:1497005300
Name:MAHALLATI, NIMA SHARIF (DC, BS, CMT)
Entity Type:Individual
Prefix:
First Name:NIMA
Middle Name:SHARIF
Last Name:MAHALLATI
Suffix:
Gender:F
Credentials:DC, BS, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24065 MADEIROS AVE
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-4462
Mailing Address - Country:US
Mailing Address - Phone:404-993-1140
Mailing Address - Fax:
Practice Address - Street 1:230 GRAND AVE STE 202
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-4559
Practice Address - Country:US
Practice Address - Phone:404-993-1140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008617111N00000X
CA33575111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor