Provider Demographics
NPI:1508237942
Name:HASHEMIPOUR MOUSSAVI, MOHAMMAD (LAC)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:HASHEMIPOUR MOUSSAVI
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 HAROLD AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-6239
Mailing Address - Country:US
Mailing Address - Phone:718-684-3050
Mailing Address - Fax:718-684-3055
Practice Address - Street 1:10 HAROLD AVE APT 2
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-6239
Practice Address - Country:US
Practice Address - Phone:718-684-3050
Practice Address - Fax:718-684-3055
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-12
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005654171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist