Provider Demographics
NPI:1568545507
Name:BIBIYAN, KEIVAN (LAC LICENSED ACUPUNC)
Entity Type:Individual
Prefix:
First Name:KEIVAN
Middle Name:
Last Name:BIBIYAN
Suffix:
Gender:M
Credentials:LAC LICENSED ACUPUNC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 PETIT AVE
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436
Mailing Address - Country:US
Mailing Address - Phone:818-789-7897
Mailing Address - Fax:818-789-2346
Practice Address - Street 1:16661 VENTURA BLVD
Practice Address - Street 2:211
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436
Practice Address - Country:US
Practice Address - Phone:818-789-7897
Practice Address - Fax:818-789-2346
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC3548171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5051622Medicare UPIN