Provider Demographics
NPI:1497179519
Name:INTEGRATIVE AND HOLISTIC CENTER FOR HORMONE BALANCING, INC.
Entity Type:Organization
Organization Name:INTEGRATIVE AND HOLISTIC CENTER FOR HORMONE BALANCING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SUDABEH
Authorized Official - Middle Name:
Authorized Official - Last Name:MOEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-465-9233
Mailing Address - Street 1:11956 BERNARDO PLAZA DRIVE
Mailing Address - Street 2:141
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128
Mailing Address - Country:US
Mailing Address - Phone:858-521-0806
Mailing Address - Fax:858-521-0808
Practice Address - Street 1:2892 JEFFERSON STREET
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008
Practice Address - Country:US
Practice Address - Phone:760-434-9500
Practice Address - Fax:619-260-0707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76561174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1619196870Medicare PIN